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AIDS Foundation of Chicago (AFC)
Northeastern Illinois Case Management Cooperative
Case Management Standard Operating Procedures (SOP) Manual
Overview of the SOP Manual
Case Management Process SOPs
SOP 1: Client Screening and Response Expectations SOP 2: Determination of Case Management Level
SOP 3: Intake
SOP 4: Confidentiality and Releases
SOP 5: Assessments
SOP 5A: Acuity
SOP 5B: Medical Assessment
SOP 6: Service Planning
SOP 7: Referrals and Linkages
SOP 8: Reassessments
SOP 9: Documentation
SOP 10: Direct Data Entry
SOP 11: Client Discharge/Case Closure
Program Administration/Quality Management SOPs
SOP 12: Grievances
SOP 13: Supervision
SOP 14: Certification and Trainings
SOP 15: Reporting
SOP 16: Quality Management and Technical Assistance
SOP 17: Site Visits
SOP 18: Satisfaction Surveys
CM Services SOPs
SOP 19: Transportation
SOP 19A: CTA and PACE Fare Cards and METRA Passes
SOP 19B: Gas Cards
SOP 19C: Taxi Service
SOP 19D: Van Service
SOP 20: Food Vouchers
SOP 21: Emergency Financial Assistance (EFA)
SOP 22: Language Translation
OVERVIEW OF THE Standard Operating Procedures MANUAL
The Northeastern Illinois Case Management Cooperative (the Cooperative) is collective body of
subcontracted agencies providing case management services to HIV-positive individuals
throughout the Chicago Eligible Metropolitan Area (EMA). The Cooperative is affiliated with
the Service Providers Council of the AIDS Foundation of Chicago (AFC) and coordinated by
AFC. The Cooperative, in existence since 1989, works to establish and maintain a consistent
process of intake, assessment, planning, service coordination, referral, follow-up, and advocacy
through which the needs of persons affected by HIV can be met. Constantly seeking to improve
the quality of HIV case management services throughout the EMA and also to remain aligned to
the ever-changing funding requirements and philosophical shifts in HIV service provision, the
Cooperative operates under this set of Standard Operating Procedures (SOPs).
This set of SOPs outlines a set of minimum standards for operational policies and procedures
that can be applied to all subcontracting agencies and that all subcontractors agree to perform.
These SOPs are not intended to serve as a comprehensive set of a subcontractor’s policies and
procedures; however, these standards serve as a minimal foundation for all subcontractors to
develop and maintain their individual agency’s case management services. Any SOP can be
supplemented by subcontractor-specific policies as long as said policies do not contradict with
the AFC SOPs.
These standards will be used by the Cooperative and its Governance Committee for utilization
reviews and quality management purposes. This document will serve as a ready reference to
subcontractors in establishing services and be used in the orientation of new subcontractors and
funded personnel to clarify Cooperative expectations. These Standard Operating Procedures
were adopted initially by a unanimous vote of the Governance Committee on March 21, 1996
and reviewed and approved in their current form by the Committee on March 25, 2008.
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 1 - Client Screening and Response Expectations
Date: September 13, 2007 Revised: February 29, 2008 Page 1 of 6
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding consistent
criteria by which clients are referred and/or assigned to case management services and to
provide a minimum standard regarding the time frame for case managers to respond to
referrals received by the AIDS Foundation of Chicago (AFC).
POLICY: All new case management clients or clients returning to case management after having
had their case management case closed will be assessed by AFC staff using the Client
Eligibility Screening for the purpose of ensuring an appropriate service referral and/or
case assignment to case management services. AFC staff will then make the appropriate
agency referral along with specific expectations for timely follow-up and engagement in
services.
PROCEDURE: An individual needing case management services must contact or be referred to the
Information and Referral Associate at AFC.
If the case management agency receives the client contact directly, AFC program staff
must be contacted by phone prior to intake to ensure that the client is not already
receiving services from another agency. When the screening is complete, AFC will
provide the completed Client Eligibility Screening Form to the agency.
The client will be screened for the need for services and the Response Expectation
established by the Cooperative. This screening will be facilitated and documented
through the use of the Cooperative’s Client Eligibility Screening Form.
Demographic information will be gathered to help determine the appropriate agency for a
client given his or her culture and geographic location. The client's expressed preference
for a service site will be considered if possible. If no preference is expressed, the client
will be assigned to an agency that most closely matches his or her cultural and
geographic community as well as the medical and social needs, whenever possible.
The Cooperative and its member agencies will ensure that needed referrals for services
are facilitated whether or not an individual is eligible for Cooperative services.
Completed Client Eligibility Screening forms and any other related documentation will
be kept as part of case management records and be made available for utilization review.
A clear determination for action based on client level of care must be documented on the
Client Eligibility Screening form. Possible determinations include the following:
• Client not eligible for case management services;
• Client referred to an agency for case management intake;
• Client does not want case management but is referred to another agency for
another service; or
• Client does not want case management services, only requests emergency
financial assistance.
The response time for a face-to-face intake appointment will be determined by the level
of client need. Client need is defined in five Response Expectations. (These should not be confused with HIV/AIDS diagnostic levels, the level of case management services, or the Coop Acuity Scale.) Criteria for determining the Response Expectation and the
timeframes for response to clients in each level are presented below.
Crisis Intervention (L4)
Crisis Intervention Criteria: A crisis is a psychosocial or medical problem expressed by
the client or determined by the case manager that requires an immediate response. This
need may result from a medical or psychosocial situation that threatens the well-being of
the client or the client's family. Possible crisis situations include:
• No home or unsafe living situation;
• Client unable to care for self and lacks a caregiver;
• Suicidal thoughts or actions;
• Medical crisis requiring emergency intervention;
• Threatened loss of housing, food or other vital resources;
• Domestic violence;
• Abuse, neglect, or threats of harm against a child or person; and/or
• Client faces immediate disruption of HIV-related medications.
This list is provided for guidance in determining the need for crisis intervention. It is not
meant to fully describe crisis situations or to limit interventions. A crisis is decisive and
a crucial event often determined by a client's reaction to a situation and a case manager's
evaluation of the need for intervention. It is important that the case manager be able to
identify a crisis when it surfaces, attempt to mitigate or resolve the immediate problem,
and use the negative event to enhance services.
AFC Response: AFC Staff will refer client same day to a case management provider,
contact with case management agency will result in referral within 24 business hours. For
cases that require immediate attention and are inappropriate for referral, AFC will advise
the client to contact 911 or will contact 911 on behalf of the client.
Case Management Response: In cases where client is not in immediate danger and a
referral is appropriate, the case manager will attempt to schedule a face-to-face contact
within 48 hours.
Immediate Response (L3)
Immediate Response Criteria: The client or family is not in crisis, but present need
requires a priority response. In this category are people with HIV/AIDS in the following
circumstances:
• Frequent and severe illness requiring hospitalization or multiple ambulatory care
visits;
• Progressive deterioration, physical or mental, requiring in-home services;
• Acute resource needs (housing, finance, food, mental health, or substance use);
• Possible child neglect, unsafe environment for children, minimal or no child care;
and/or
• Client request for Emergency Financial Assistance only.
AFC Response: AFC Staff will arrange for a case management referral within 24 hours.
Case Management Response: The case manager will arrange a plan for intervention
with a face-to-face contact within 3 working days.
Intermediate Response (L2) Intermediate Response Criteria: The client or family has intermediate needs. In this
category are people with HIV/AIDS in the following circumstances:
• Client is symptomatic with no primary care services in place;
• Symptoms and/or coping skills are interfering with client's ability to parent
children or perform job;
• Inadequate or dysfunctional family or support system;
• Emotional difficulty because of HIV status;
• Multiple needs for any combination of health, mental health, and substance abuse
screening/services;
• Intermediate or long-range resource needs (housing, food, etc.);
• Educational needs for HIV/AIDS self care, in-home care, HIV transmission
risk/harm reduction; and/or
• Children in household are receiving minimal or no counseling/support services;
school attendance irregular; behavior problems reported.
AFC Response: AFC Staff will arrange a case management referral within 3-5 business
days.
Case Management Response: The case manager will arrange a plan for intervention
with a face-to-face contact within 10 working days.
Low Priority Response (L1) Low Priority Response Criteria: The client, family, or caregiver has clearly identified
needs but is able to postpone or wait for intervention. In this category are people with
HIV/AIDS in the following circumstances:
• Seeking education, support, and future planning assistance while maintaining
health, employment, and daily living tasks;
• HIV asymptomatic, with no expressed stress or anxiety, seeking a primary care
provider;
• Caregiver or family member seeking information, education, or other assistance;
and/or
• Client needs an assessment for Emergency Food Voucher and/or Transportation
eligibility.
AFC Response: AFC Staff will attempt to screen for social support case management
services. Referral will be made within 3-5 business days.
Case Management Response: The case manager will arrange a plan for intervention
including face-to-face contact within 20 working days.
In general, Low Priority Response cases should be closed after the intervention has
resolved the clients identified needs. The client is encouraged to contact AFC or the case
management agency directly if additional information or services are needed.
No Response
No Response Criteria: One of the following criteria must be met in order to assign a
client to No Response:
• Client expresses a desire for one-time information and referral only; and/or
• Client is not currently eligible for services.
AFC and Case Management Response: The client is encouraged to contact AFC or the
case management agency in the future if additional information or services are needed.
The client’s case record will not be opened or active. The client will not be assigned to a
case management agency.
FORMS: Client Eligibility Screening Form
AIDS FOUNDATION OF CHICAGO NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE
CLIENT ELIGIBILITY/PLACEMENT SCREENING FORM
Staff Completing: ____________________ Screening Date: ________________ Last Name: __________________________ First Name: ________________ MI: ______ Date of Birth ____/____/________ Gender __Female __ Male __ Trans__ Other Social Security Number: _______/______/_____________ Address: _______________________________ City: ________ Zip: _________County ___________ Phone # :( __) ________ Should confidentiality be observed when contacting this client? __ YES __ NO Emergency Contact Name: ________________ Relationship: ________________ Phone #:( ___ )_______________ Is Emergency Contact aware that you are HIV positive? __YES __ NO When were you diagnosed with HIV? ___/____/_____ (If client is female) Are you currently pregnant? __ YES __ NO Have you been incarcerated during the last 12 months? __ YES __ NO
Primary Care (Please tell me about your current primary care situation. Do you have a doctor? How is your
current health?) __ Medical crisis requiring emergency intervention. (L 4) __ Recent discovery or change of HIV status requiring immediate supportive counseling (L 4) __ Frequent and severe illness requiring hospitalization and/or multiple ambulatory care visits (L 3) __ Progressive physical or mental, deterioration requiring in-home services (L 3) __ Client is symptomatic with no primary care services in place (L 2) __ Physical symptoms and/or inadequate coping skills are interfering with self care or dependant care (L 2) __ Asymptomatic, with no expressed stress or anxiety, but not currently in care (L 1) __ Currently seeing a doctor and active in care (L0)
Mental Health (Tell me a little about your current emotional state. Are you currently in or have you ever
been in counseling?) __ Suicidal thoughts or actions. (L 4) __ Request for immediate supportive counseling. (L 4) __ Emotional symptoms and/or inadequate coping skills are interfering with self care or dependant (L 4) __ Experiencing mental health issues and receiving stable treatment for them (L2) __ Emotional difficulty in response to HIV status (L 2) __ Seeking education, support and future planning assistance while maintaining health, employment and daily living tasks (L 1) __ No identified mental health issues (L0)
Substance Use (I will ask you some sensitive questions about substance use, please answer honestly and to
the best of your ability.) Have you ever tried to reduce or cut-down your alcohol/drug use? __ YES __NO Have you ever been annoyed when people mention the amount of your alcohol/drug use to you? __ YES __NO Have you ever felt guilty about the amount or frequency of your alcohol/drug use? __ YES __NO Have you ever had to use alcohol or drugs first thing in the morning? __ YES __NO (3 questions with a YES, are ranked as a Level 3. 2 questions with a YES, are ranked as a Level 2)
Housing (Tell me about your current living situation.) __ Homeless or unsafe living situation (L 4) __ Threatened with loss of food, or other vital resources (L 3) __ Intermediate or long range resource planning needed (housing, food, etc) (L 2) __ Stable rental or owned property (L 1)
Income/Resources (What is your current income?) __ No income (L 3) __ Requires assistance/advocacy for entitlements (L 2) __ Employment or income support needed (L 1) __ Income Stable (Source ____________, Monthly amount $__________)
AFC CLIENT ELIGIBILITY/PLACEMENT SCREENING FORM Page 2
Dependants’ needs (Do you currently have dependants? Are they in your care?) __ Domestic violence: child abuse or neglect, unattended young child, threatened harm against children (L 4) __ Possible child neglect or dependency, unsafe environment for children, minimal or no child care (L 3) __ Open DCFS case (L3) __ Children in household are receiving minimal or no support, irregular school attendance, behavior problems reported (L 2) __ Care giver or family member seeking information, education, or other assistance (L 1) __ No client or dependant needs identified (L 0)
Assessed Level of Care: (Level of care is determined based on the most common level of care assessed in the
above domains. Of the five levels, the most frequently level is the level of care assigned to the client. However, is a
client receives a Level 4 in any category, they are to be assigned to that level) Level 4 ____: AFC Response: AFC Staff will refer client same day to a case management provider, contact with case management agency will result in referral within 24 hours. Crisis Case Management Response: A case manager will contact client and maintain telephone contact until a plan for intervention satisfactory to the client can be arranged. The case manager will attempt to schedule a face-to-face contact within 48 hours.
Level 3 ____: AFC Response: AFC Staff will arrange for a case management referral within 24-48 hours. Case Management Response: The case manager will arrange a plan for intervention with a face-to-face contact within 3 working days. Level 2 ____: AFC Response: AFC Staff will arrange a case management referral within 3-5 business days. Case Management Response: The case manager will arrange a plan for intervention with a face-to-face contact within 10 working days.
Level 1 ____: AFC Response: AFC Staff will attempt to screen for social support case management services. Referral will be made within 3-5 business days. Case Management Response: The case manager will arrange a plan for intervention including face to face contact within 20 working days.
Level 0____: AFC and Case Management Response: The client is encouraged to contact AFC or the case management agency in the future if additional information or services are needed. The client’s case record will not be opened or active.
Assigned Date: _____/_____/_________ Assigned Agency: ___________________
Assigned Case Manager/Supervisor: ___________________________
Notes:
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 2 – Determination of Case Management Eligibility and Level
Date: December 2007 Revised: February 29, 2008 Page 1 of 2
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the assignment
of case-managed individuals into one of several levels of case management according to
client need.
POLICY: Individuals seeking case management services will be assigned to the type of case
management most appropriate to severity of need, situational eligibility, and life
circumstances. Levels of case management include intensive, medical, and supportive
services case management.
PROCEDURE: The Cooperative and the AIDS Foundation of Chicago (AFC) provides several types of
case management. These include Ryan White Part A and Part B medical case
management and supportive services case management as well as intensive case
management programs: Department of Rehabilitative Services (DRS), Corrections,
Supportive Housing Program (SHP), Chicago Housing and Health Partnership (CHHP),
and Pediatric AIDS Chicago Prevention Initiative (PACPI). Specific eligibility criteria
for each program are outlined below:
Intensive DRS Case Management
• Must be a U.S. citizen;
• Must be a resident of Illinois;
• Has a severe disability which will last at least 12 months;
• Has a need for long-term care based on the Determination of Need;
• Must have physician approval;
• Assets cannot exceed $10,000 for an individual or $30,000 for a family (if client
is under 18); and
• Must apply for Medicaid or be receiving Medicaid.
Intensive Corrections Case Management
• Must be HIV+;
• Recently released from prison and/or jail within the last 12 months; and
• Not currently receiving Ryan White case management.
Intensive SHP Case Management
• Must be HIV+;
• Low-income as defined by HUD (80% of the Area Median Income.)
• Homeless or at imminent risk of homelessness;
• Mental illness or substance abuse disorder; and
• Documented numerous visits to the county hospital and/or jail systems.
Intensive CHHP Case Management
• Chronic medical illness, history of hospitalization;
• Referral comes from hospital social worker;
• Mental capacity to understand the program;
• Not currently incarcerated; and
• Does not have primary guardianship.
Intensive PACPI Case Management
• Must be an HIV+, pregnant woman; and
• Especially for high-risk pregnancies – substance use, mental health, no prenatal
care, other complicating medical or social factors.
Ryan White Part A and Part B Case Management
For Both Medical and Supportive Services Case Management • Must be HIV+;
• Must be a resident of the Chicago Eligible Metropolitan Area (EMA); and
• Should have identified case management needs beyond intake and referral.
For Medical Case Management Criteria establishing the level of need required for assignment to medical case
management are still being finalized by AFC. The determination will rely on information
gathered in the Intake, Reassessment, and Acuity tools outline in SOPs 3, 5, and 8 and
conducted during routine face-to-face encounters with clients. AFC is implementing the
following criteria to determine assignment to medical case management services:
• All clients who have been diagnosed as HIV-positive within the last 18 months;
• All clients who do not have a stable medical provider;
• All clients who identify a stable medical provider, but who have not had an
actualized visit on over 6 months; and/or
• All clients who have demonstrated non-adherence to prescribed medications.
AFC will also be determining a client’s need for medical case management services
based on access and adherence to mental health, substance abuse, and oral health
treatment. Those guidelines will be available in late Spring 2008.
In general, screening at AFC will result in an individual being assigned to the most
intense case management program he or she is eligible for. However, full eligibility and
level of case management will be determined by case manager assessment using the tools
mentioned above as well as the client’s preference (the client can request a less intense
level, but not a more intense level.) Clients can transfer from one type to another as life
situations change. These transfers can be initiated at the case management agency but
should then be confirmed by the appropriate AFC program staff.
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 3 - Intake
Date: March 21, 1996 (Previously SOP 2)/ Revised: February 29, 2008 Page 1 of 7
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the process for
gathering required intake information and assessing client’s current needs.
POLICY: Client intakes will be completed by the assigned case manager on a timely basis (based on
Response Expectation identified during the AIDS Foundation of Chicago (AFC) screening, see
SOP 1) and will include documentation of eligibility, demographic information, and an
assessment of client needs.
PROCEDURE: Intake is the process by which a case manager forms a relationship with the client, documents
eligibility, and gathers information necessary to determine the initial assessment of need and
preliminary service plan.
Intake is conducted by a case manager of a Cooperative agency in a face-to-face interview with a
client eligible for services. Intakes may be conducted in an agency office, a client's home, or at a
health or social service institution. In any case, the intake must be conducted in a confidential
setting.
During intake the case manager will verify screening information and the need for case
management services, explain the case management system and services provided, collect client
data, and prioritize areas of need. Case managers will maintain client confidentiality regarding
the information shared and describe the policy on confidentiality to the client.
With this information, the case manager will formulate and share with the client an assessment of
service needs and suggest areas of focus for the service plan. Either in the initial intake session
or in a next meeting with the client, the case manager and client will develop a formal service
plan to guide the case management relationship. (See SOP 6 for details on Service Planning.)
Below is a list of all documentation that must be obtained to complete an initial intake
assessment:
• Client Screening Feedback Form (received from AFC) (SOP 1)
• Acuity scale (Parts 1 and 2) (SOP 5A)*
• Consent to Enroll in the Central Database (SOP 4)
• Consent to Participate in Case Management (SOP 4)
• AFC Release of Information (SOP 4)
• Case Intake Form*
• Medical Assessment Form (completed by physician) (SOP 5B)*
• Photo ID
• Proof of Residency
• Proof of Income
• Proof of HIV Status
• Client Rights and Responsibilities (agency-specific form)
• Grievance Policy (agency-specific form)
• HIPAA Policy (when applicable)
• Updated Service Plan (SOP 6)
* Must be entered into AFC’s client-level data system
This list is also available in the Ryan White Initial Assessment Checklist, which includes specific
information on each required item. In cases where clients do not have income or health
insurance, AFC will accept a letter signed by both the client and case manager affirming that the
client has no source of income or insurance as adequate documentation. Case managers should
use this tool when completing the intake.
FORMS: Case Intake Form
Ryan White Initial Assessment Checklist
AIDS FOUNDATION OF CHICAGO
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE INTAKE FORM
INTAKE DATE: ____ ____ / ____ ____ / ____ ____ CLIENT ID #: ________________________ AGENCY: _____________________________________CASE MANAGER: ___________________________________________________
REFERRAL SOURCE: AFFILIATION:
PHONE #: ( __ __ __ )__ __ __ - __ __ __ __
LAST NAME: _____________________________________________ FIRST: ________________________________________________ MI:
________
DOB: ____ / ____ / _________ GENDER: M ���� F � � � � M to F ���� F to M � � � � U � � � � SS#: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
--CHECK ONLY ONE IN EACH OF THE FOLLOWING CATEGORIES (Must indicate an ETHNICITY & a RACE)-- MARITAL STATUS:
DIVORCED _____
MARRIED _____
SEPARATED _____
WIDOWED _____
ENGAGED _____
PARTNERED _____
SINGLE _____
UNKNOWN _____
HIGHEST EDUCATION LEVEL
COMPLETED:
GRADE SCHOOL _____
SOME HIGH SCHOOL _____
HIGH SCHOOL GRADUATE _____
SOME COLLEGE _____
ASSOCIATE’S DEGREE _____
UNDERGRADUATE DEGREE _____
GRADUATE DEGREE _____
VOCATIONAL DEGREE _____
ETHNICITY:
Hispanic/Latino/a Yes ____ No ____
Mexican ____
Puerto Rican ____ Other Hispanic ____
RACE: WHITE ____
BLACK/AFRICAN AMERICAN ____ ASIAN _____
HAWAIIAN/PACIFIC ISLANDER _____ AMERICAN INDIAN _____
MORE THAN ONE RACE _____ UNKNOWN _____
OTHER _____
PRIMARY LANGUAGE:
_______________________
_______________________
TOTAL NUMBER IN HOUSEHOLD: ______
TOTAL NUMBER OF DEPENDANTS: _______
PRIMARY CARE SOURCE:
PRIVATE PRACTICE ____ HMO ____
COMM. HEALTH CTR. ____ HOSPITAL CLINIC ____
OTHER CLINIC ____ EMERGENCY ROOM ____
OTHER ____ NONE ____
SOURCE OF REFERRAL:
CASE MANAGER _____ COURT SYSTEM _____
DCFS _____ FAMILY & FRIENDS _____
HIV COUNSELING & TESTING SITES _____ HOTLINE _____
MEDIA _____ OTHER AGENCY _____
OTHER UNIT IN PROVIDER AGENCY _____ PRIMARY CARE PROVIDER _____
STD CLINICS _____ SELF REFERRAL _____
SEROSTATUS: *
AIDS DIAGNOSIS ____ HIV+/ NOT AIDS _____
HIV+/ AIDS UNKNOWN _____ UNKNOWN _____
RISK FACTOR:
MSM/BISEXUAL _____
IDU _____ MSM/IDU _____
HEMOPHILIA _____ HETEROSEXUAL _____
TRANSFUSION _____ PARENT HIV+ _____
OTHER _____
UNKNOWN _____
DEMOGRAPHICS/CONTACT INFORMATION
ADDRESS: __________________________________________ CITY: _________________________ COUNTY: __________________ ZIP: __________
PHONE: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___ OTHER PHONE/CELL: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
#1 EMERGENCY CONTACT: _____________________________ RELATIONSHIP: ___________________ PHONE:( __ __ __ ) __ __ __ - __ __ __ __
IS THE #1 EMERGENCY CONTACT AWARE THAT THE CLIENT IS HIV+? YES ���� NO ���� #2 EMERGENCY CONTACT: _____________________________ RELATIONSHIP: ____________________ PHONE:( __ __ __ ) __ __ __ - __ __ __ __
IS THE #2 EMERGENCY CONTACT AWARE THAT THE CLIENT IS HIV+? YES ���� NO ����
INFORMAL SUPPORTS (HOUSEHOLD MEMBERS)
NAME RELATIONSHIP GENDER DOB/AGE RACE ETHNICITY
*At intake, acceptable documentation of serostatus, Photo ID, and proof of residency must be provided by the client and recorded in the client case management record. Page 1
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE INTAKE FORM Page 2
LIVING ARRANGEMENT CURRENT TYPE:
INSTITUTION HOUSING PROGRAMS COMMUNITY � � � � HOSPITAL
� � � � INSTITUTION
� � � � JAIL, CORRECTIONAL FACILITY
� � � � PSYCHIATRIC HOSPITAL
� � � � GROUP OR FOSTER HOME
� � � � SHELTER
� � � � SUPPORTIVE HOUSING UNIT
� � � � SUBSTANCE ABUSE FACILITY
� � � � TRANSITIONAL HOUSING
� � � � HOMEOWNERSHIP
� � � � HOTEL/MOTEL
� � � � RENTAL UNIT
���� SRO
� � � � STREET
� � � � OTHER
� � � � UNKNOWN/UNREPORTED
CURRENT HOUSING START DATE: ____/____/______
INCOME SOURCES:
How much money did you receive from the following sources in the past 30 days? Amount Start Date End Date
Employment/wages/salary (net income) $ __________ __/__/____ __/__/____ Unemployment/workers compensation $ __________ __/__/____ __/__/____ Public assistance/AFDC/welfare $ __________ __/__/____ __/__/____ Child support/alimony $ __________ __/__/____ __/__/____ Pension/benefits/Social Security $ __________ __/__/____ __/__/____ Partner, family or friends $ __________ __/__/____ __/__/____ (money for personal expenses) $ __________ __/__/____ __/__/ ____ Other Income: _________ $ __________ __/__/____ __/__/____
INSURANCE SOURCES:
Insurance Types: AIDS Drug Assistance Program, IL All Kids, CHIC, GA (General Assistance), Medicaid, Medicare, None, Other, Private Insurance, Other Public Insurance, VA Benefits
Insurance Type Medications Covered? Y/N Primary? Y/N Start Date End Date
_______________ _________________________ ________ ___/___/_____ ___/___/_____
_______________ _________________________ ________ ___/___/_____ ___/___/_____
_______________ _________________________ ________ ___/___/_____ ___/___/_____
_______________ _________________________ ________ ___/___/_____ ___/___/_____
HEALTH CARE INFORMATION: (1HEALTHINF)
Date of HIV Diagnosis: __/__/____ Are you currently in medical care for HIV? � Yes � No
If yes, how long have you been in care? � Less than a year � 1-2 years � 2-3 years � 3 Years or More Date of Last Medical Visit: ___/___/_____ Applied for ADAP: � Yes � No Date Applied: __/__/____ Currently Receiving ADAP Drugs: Yes � No � Applied for CHIC: � Yes � No Date applied: __/__/____ Currently Receiving CHIC: Yes � No � Applied for Medicaid: � Yes �No Date Applied: __/__/____ Currently Receiving Medicaid: Yes � No �
If not on one of the above programs; how are you receiving your medications?
Primary Care Provider: Name: _________________________________ � None � Don’t know Phone: _______________
Type of Physician (I.e., Infectious Disease, General Practitioner, Nurse Practitioner): __________________________
Address:
Hospital/Clinic Affiliation: Date of last CD4 count? __/__/____ Have you been prescribed medications for your HIV? �Yes (continue) �No How often do you feel that you have difficulty taking your HIV medications on time? By “on time” we mean no more than two hours before or after the time your doctor told you to take it. � Never � Rarely � Most of the time � All of the time On average, how many days PER WEEK would you say that you missed at least one dose of you HIV medications? � Never � 1-3 days per week � 4-6 days per week � Every day When was the last time you missed at least one dose of your HIV medications?
� Never � More than two weeks ago � 1-2 weeks ago � Within the past week
Date you last took HIV medications:
Date of last HIV-related medical appointment? ___/___/_____
Are you currently pregnant? � Yes � No
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE INTAKE FORM Page 3
HEALTH CARE INFORMATION (continued): Please select all the medical conditions that a doctor, nurse, or other medical provider has told you that you have: � None � Endocarditis/Infection of Heart Valve � Hepatitis C � Other permanent numbness� Arthritis � Epilepsy � Hypertension � Paralysis � Asthma/Emphysema � Glaucoma � Liver Disease � Tuberculosis � Diabetes � Heart Disease � Obesity � Stroke � Cancer (Please specify type): � Other ________________________________
LEGAL HISTORY (Check all that apply): (2LEGAL) � No criminal background
� Felony conviction(s) � Misdemeanor conviction(s) � Been in jail Date of most recent release __/__/____ � Been in prison Date of most recent release __/__/____ � Currently under: (circle one) parole probation supervision � Court date(s) __/__/____ � Arrest(s) � Required to register as sex offender: (circle one) adults children � Other____________________________
MENTAL HEALTH: (3MENHLT)
Have you ever received treatment for any psychological condition? Yes ���� No ���� If yes, what was the treatment for:
���� Schizophrenia ���� Depression ���� Bipolar Disorder ���� Personality Disorder ���� Anxiety Disorder
���� Others: ________________________________________________________
���� Was treated, but does not know diagnosis, but their symptoms are: ____________________________________________ Have you ever been hospitalized for a psychiatric condition? Yes � No � If yes, how many times? ______
Name of hospital (most recent): Dates of hospitalization: __/__/____
What were the circumstances? _________
Have you ever taken medication for psychiatric and emotional problems on a daily basis? Yes ���� No ���� If yes, what is your current course of treatment? Current Medications:
Have you been able to follow through with taking the prescriptions? Yes ���� No ���� Please explain:
Have you been able to follow through with doctors and counseling appointments? Yes ���� No ���� Please explain:
In the past six (6) months, have you considered harming yourself or others? Yes ���� No ���� If yes, please explain:
SUBSTANCE USE (4SUBSTUSE)
How many times in your life have you been treated for . . . ? (if none, code 0; if refused, code 77; if don’t know, code 88) Alcohol abuse l___l___l Drug abuse l___l___l
Type(s) of Drugs Number of Days Used in Past 30 Days # Years Used
□ Alcohol – any use at all ______________ _______ □ Alcohol to Intoxication ______________ _______ □ Heroin ______________ _______ □ Methadone ______________ _______ □ Other Opiates/Analgesics ______________ _______ □ Cocaine or Crack ______________ _______ □ Amphetamines/Speed ______________ _______ □ Marijuana/Hash ______________ _______ □ Hallucinogens /LSD/Mushrooms ______________ _______ □ Inhalants/Poppers ______________ ______ □ More than 1 substance in 1 day (incl. alcohol) ______________ _______
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE
CASE INTAKE FORM Page 4 Eligibility Checklist for Client Services: (5TRANFOOD) Food Assistance
� � � � Client’s income is at or below 50% of the area median income to be eligible. (Documentation of income to be kept in chart, and documented above in Income Sources.) � � � � Client affirms that they do not receive assistance from Public Aid (Link Card) � � � � Client affirms that they are not receiving food from Vital Bridges � � � � Client affirms that they are not able to access local food pantries Clients must meet ALL of the above eligibility criteria to receive emergency food voucher assistance.
Client is eligible: YES ���� NO ���� CTA/Metra/PACE Transportation:
� � � � Client’s income is at or below 50% of the area median income to be eligible. � � � � Client affirms that he/she has no family or friends that can transport him/her to appointments � � � � Client affirms that there are no clinic/hospital van services available � � � � Client affirms that he/she does not have an RTA reduced fare card and is not eligible � � � � Client affirms that he/she does not have an active medical card
Clients must meet ALL of the above eligibility criteria to receive CTA/Metra/PACE transportation assistance.
Client is eligible: YES ���� NO ���� Taxi Services:
� � � � *Client’s income is at or below 50% of the area median income to be eligible. � � � � *Client affirms that he/she has no other transportation resources available to them. � � � � *Client affirms that he/she does not have an active medical card. � � � � *Client affirms that he/she does not have an RTA reduced fare card and is not eligible. � � � � Client has demonstrated difficulty ambulating (i.e. cannot climb stairs, cannot walk more than 20 feet) � � � � Client has a documented physical disability that impedes safe access to public transportation. � � � � Client affirms that public transportation does not serve point of origin or destination. � � � � Client affirms that he/she is traveling with two or more infants or toddlers.
*Client must meet ALL of the first four eligibility criteria and at least one of the remaining four eligibility criteria in order to be eligible to receive taxi transportation assistance.
Client is eligible: YES ���� NO ����
I have participated in the completion of this document for planning of my care. I certify that all information provided is accurate and truthful to the best of my knowledge. I understand that I may deemed ineligible for services based on some of the responses to these questions. ______________________________________ _____/____/_________ Client or Legal Guardian signature Date
______________________________________ _____/____/_________ Case Manager Date
Ryan White Initial Assessment Checklist (To be completed at intake for all Ryan White clients)
Forms/Documentation Date Completed/Received
Client Screening Form (received from AFC) ____________
Acuity Scale (AFC forms Parts 1 and 2) ____________
Consent to Enroll in Central Database (AFC form) ____________
Consent to Participate in Case Management (AFC form) ____________
AFC Consent to Release Information (AFC form) ____________
Case Intake Form (pages 1-4) (AFC form) ____________
Medical Assessment to Physician (AFC form) Date Sent: ____________
Date Received: ____________
Client Photo ID (Drivers License/State ID) ____________
Client Proof of Residency ____________
� Utility bill with client name and current address
� Driver’s license or state ID with current address
� Documents issued by the state or federal government (i.e. a motor vehicle registration form, a current Illinois voter registration card, or a current Medicaid card)
� Current rental or lease agreement with client name
Client Proof of Income ____________
� Current pay stubs – 1 month’s worth
� Most recent W2 forms
� Unemployment Benefits Statements
� Most recent SSI benefits statement
� For clients with no income, a verification letter must be completed, signed and dated by client and cm
Client Proof of HIV Status ____________
Client’s name must be on any of the following:
� Medical Assessment with diagnosis identified
� Official lab result with any detectable viral load
� Positive ELISA & Western Blot
� Positive Serology assay
� Positive DNA PCR assay
Client Rights and Responsibilities (Agency Form) ____________
Client Grievance Policy (Agency Form) ____________
HIPAA Policy (when applicable) (Agency Form) ____________
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 4 – Confidentiality and Releases of Information
Date: March 21, 1996 (Previously SOP 8) Revised: February 29, 2008 Page 1 of 13
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding ensuring confidentiality
of client records and the process for legally releasing client information.
POLICY: All client information is confidential and must follow appropriate protocols before it can be
released. Case managers must inform clients of confidentiality protocols and have clients sign all
requisite confidentiality policies and releases at intake and annually thereafter (when
appropriate).
PROCEDURE: Confidentiality ensures that information regarding a client's HIV status (positive or negative),
behavioral risk factors, or use of services cannot be released without his or her documented
consent. The Cooperative has established written policies and procedures that are in compliance
with the Illinois AIDS Confidentiality Act. Subcontracted agencies must take the necessary
steps to ensure that their practice conforms to these policies and procedures.
For the purposes of planning and funding, the AIDS Foundation of Chicago (AFC) must also
ensure that reporting requirements accurately depict client-level service utilization while
protecting client identity and ensuring the highest possible standard of security. Case managers
are required to counsel clients regarding this policy.
Consent to Enroll in Central Database and Participate in Case Management Services Form
All clients requesting case management services must be informed of and sign the “Consent to
Enroll in Central Database and Participate in Case Management Services” form at intake before
any services can be provided and reported. This form sets the expectations for client contact for
case management services and the consequences of non-compliance, abuse and threats, and other
safety concerns. This form allows for the entry of client identifying information into AFC’s
client-level data system and the verification of the client in the system. No identifying information can be collected without the additional signature on a Consent for Release of Information.
Cooperative Consents must be obtained at the time of case management intake to enroll clients in
the AFC database. They allow AFC to receive protected health information and permit the case
manager to verify previous enrollment in database. Appropriate consents must be signed by any
client receiving a service provided and funded by the Cooperative; these services include but are
not limited to any level of case management services, Part B direct services, Part A funded
services (transportation, emergency financial assistance, emergency food vouchers, and
emergency housing assistance) and non-case management affiliated prevention services where
electronic records are maintained on AFC’s client-level database.
Consent to Release of Information
The Consent to Release Information form allows for the sharing of client information between
AFC and its case management subcontractors. It also allows for a limited amount of information
to be shared between case management subcontractors for the purposes of service coordination
and client transfer. The Consent to Release Information allows for AFC Program Staff and
oversight committees (i.e. Governance, Consortia Advisory, etc.) to review program files for
quality assurance purposes. No client information beyond the initial AFC screening (SOP 1) can
be shared with AFC until the Consent to Release Information form is signed by the client. The
form must be signed at intake and annually thereafter.
The Consent to Release Information form ensures that information will be solely provided for the
purposes of coordinating and funding services and will not be disclosed to any government
agency or health department for purposes of surveillance, contact tracing, or any other purpose
other than obtaining health care or social service utilization. Except (1) with client consent, (2)
as required by law, or (3) if necessary, to prevent a serious attempt to inflict harm to self or
others. Security precautions will be maintained to prevent unauthorized access to the database
by anyone other than AFC Program Staff.
If a client refuses to sign the Consent to Release Information, the case manager must indicate so
on the signature line and place the form in the client chart. The case manager must make every
effort to inform the client of the purpose of the form as well as the ramifications for not signing
the form, but must not be coercive in forcing the client to sign. NO information is to be submitted to AFC for reporting purposes and client must be informed that they are ineligible for services that require verification of diagnosis or identity. For example, Part A funded transportation
services (fare cards or taxis), cannot be provided without verifying eligibility and supporting
documentation; therefore a client cannot access these services without signing the Consent to
Release Information form.
Client Confidentiality and External Releases of Information
Before a case manager discusses or shares information about a client with another organization
or individual, the client must agree to and document so by signing a Release of Information must
be signed by the client. A Release of Information may be in the agency’s internal format as long
as it includes at minimum: the receiving entity, the receiving individual (then appropriate and
necessary), the nature of information to be shared, the duration of the consent agreed upon by the
client, the client and case manager’s signatures, and the identifying information of the client
(address and/or social security number). The Release of Information must be a part of the case
management chart and may also be faxed, mailed, or physically distributed to the receiving
entity.
The Cooperative and case managers may release information without client approval under the
following circumstances only:
• When records are subpoenaed and legal counsel confirms that information must be
shared. In such cases, the client will be informed of the information shared, if legally
possible, before AFC does so; or
• In the event of a medical emergency when the client, guardian, or caretaker is unable to
provide consent.
FORMS:
Consent to Enroll in Central Database and Participate in Case Management Services Form
Consent to Release Information Form
CONSENT TO ENROLL IN CENTRAL DATABASE AND PARTICIPATE IN CASE
MANAGEMENT SERVICES PROGRAM
I. CONSENT TO ENROLL IN CENTRAL DATABASE
I, (enter client’s name) _____________________________________, consent to enroll
in the centralized client database established by the AIDS Foundation of Chicago (the
“Database”) to assist and monitor the enrollment of persons receiving case management and
direct services through the Northeastern Illinois HIV/AIDS Case Management Cooperative (the
“Cooperative”). I understand that my participation in the Database is dependent upon my
completion of a separate and distinct form consenting to the release of my medical information
to the Database.
In connection with my enrollment in the Database, I hereby allow the following
information to be furnished to the AIDS Foundation of Chicago for entry into the Database: my
name (where applicable), date of birth, mother’s maiden name, any positive or negative HIV
status and other demographic data. I understand that this information will be grouped together
with that of other clients for the purpose of generating statistical reports, avoiding duplication of
services and coordinating a system for service delivery to persons with or at risk of HIV, their
family members, and/or significant others and specifically authorize the use of such information
for that purpose.
II. CONSENT TO PARTICIPATE IN CASE MANAGEMENT SERVICES PROGRAM
I, (enter client’s name) _____________________________________, consent to
participate in the case management services program (the “Program”) offered by the
Northeastern Illinois HIV/AIDS Case Management Cooperative (the “Cooperative”).
The Cooperative is a sub-unit of the AIDS Foundation of Chicago, a non-profit
organization. The Cooperative assists persons with HIV infection, their dependants and/or their
legal guardians in obtaining medical and social services as may be required from time to time. A
large number of social service agencies work with the Cooperative to provide a full range of
services to each client.
The Cooperative’s case management services are offered to persons with HIV infection,
their dependants and/or their legal guardians regardless of their ability to pay. Where
appropriate, the Cooperative will negotiate with private insurance companies and/or IDPA for
payment.
During my participation in the Program, my case manager and I will agree on my medical
and social needs and my needs will be addressed via referral to appropriate agencies or service
systems. During my participation in the Program, I will discuss my needs with my case manager
on a regular basis to determine if any changes in planned services are in order.
I will continue to participate in the Program and receive the case management services
offered by the Cooperative unless I choose, at any time, to refuse such services or if I am
discharged from participation in the Program for one or more of the following reasons:
1. Non-compliance with my service plan (for example, being out of contact
with my assigned case manager for three months or more);
2. Making threats to Cooperative staff or others with a likelihood that I will
act on such threats; or
3. The existence of problems of environmental safety that threaten the well-
being of my case manager or myself.
Should one of these occur, I understand that I may be restricted from receiving case
management services from Provider.
I agree to notify my case manager of any significant changes in my status (physical,
mental, social, economic or other) or of any intent I may have to change my participation in the
plan of care developed for me in connection with my participation in the Program.
_____________________________________ Signature of Client or Client’s Legal Representative
_____________________________________ Print Name
_____________________________________ Date
_____________________________________ Relationship (if signed by person other than Client)
FORM REVISED 8/2004; EFFECTIVE DATE 10/1/2004
FORM REVISED 8/2006; EFFECTIVE DATE 9/12/2006
CONSENT TO RELEASE INFORMATION
Subject to the limitations and conditions set forth below, I, ___________________hereby
consent to __________________________________ (“Provider/Case Manager”), acting
through its employees or agents, to use and/or disclose my health information and medical
records to the AIDS Foundation of Chicago, the Northeastern Illinois HIV/AIDS Case
Management Cooperative (the “Cooperative”) and/or any agencies that provide services through
the Cooperative (collectively the “Recipients”), as follows: (i) in connection with my
participation in the centralized client database established by the AIDS Foundation of Chicago
(the “Database”) and the operation of the client database; (ii) to enable the AIDS Foundation of
Chicago and the Cooperative to conduct quality assurance programs for individuals receiving
case management services through the Cooperative; (iii) to avoid duplication of services by case
management agencies; and (iv) in connection with the submission of reports and other data to
funding sources.
In connection with my enrollment in the Database, I hereby give my consent for the
following information to be furnished to the AIDS Foundation of Chicago for entry into the
Database: my name (when applicable), date of birth, mother’s maiden name, and other
demographic data. In addition, verification of HIV positive status (if applicable) and dates of
medical and case management service will be released to the AIDS Foundation. I understand that
this information will be grouped together with that of other clients for the purpose of generating
statistical reports, avoiding duplication of services and coordinating a system for service delivery
to persons with HIV, their family members, and/or significant others and specifically authorize
the use of such information for that purpose.
I further allow the program staff of the AIDS Foundation of Chicago and its designated
Oversight Committees of the Cooperative to review my individual service records as part of the
Cooperative’s quality assurance program. For the purposes of this consent, I acknowledge and
agree that my service records include any and all records generated by any of the Provider
agencies that participate in the Cooperative.
Any information I provide for the purposes of receiving services will not be
disclosed to any government agency or health department for purposes of surveillance,
contact tracing, or any other purpose other than obtaining health care or social services,
except (1) with my consent, (2) as required by law, or (3) if necessary, to prevent a serious
attempt to inflict harm on myself or others. Security precautions will be maintained to
prevent unauthorized access to the Database by anyone other than the program staff of the
AIDS Foundation of Chicago.
I give further consent to allow the AIDS Foundation of Chicago to report information that
I provide in connection with my enrollment in the Database and in connection with my receipt of
services to the federal grant programs that support the AIDS Foundation of Chicago. I
understand that such information may be provided either in the aggregate or on an individualized
basis. I understand that, in order to protect my privacy, any information that is provided on an
individualized basis, with the exception of Title II funded service utilization, will be furnished
using unique client codes, without names or other information that identifies me.
I further understand that should I receive service funded under Title II of the Ryan White
CARE Act, certain information will be reported to the Direct Services Unit of the Illinois
Department of Public Health, including:
- demographic information, including but not limited to name, gender, race, ethnicity, and
birth date; service utilization information; HIV/AIDS diagnosis and treatment information, if
any; and mental health and/or substance use diagnosis, treatment, and service information, if any.
I understand that this information will be shared for the purposes of evaluating Title II
service utilization patterns, on-site service reviews, and when necessary to coordinate services.
I further agree that the Direct Services Unit of the Illinois Department of Public Health
may disclose this same type of information to my provider/case manager, and/or the
Cooperative.
I can terminate this consent by submitting a written request to any of the Recipients
(agencies in the Cooperative) indicating that I no longer desire to receive services through the
Cooperative, or my written revocation of this authorization, whichever occurs first.
I understand that I may refuse to sign this consent and that may result in being denied
services, if eligibility for services is based on the verification of my diagnosis and the release of
that information. I understand that I have the right to receive a copy of this consent. I further
understand that I may revoke this consent at any time by providing written notice of my intent to
revoke this consent to Provider. This consent cannot be revoked to the extent that action has
already been taken based on this consent.
This consent is valid for a period of one year from the date of the actual client signature
below.
Provider will not use or disclose personal health information beyond the scope of this authorization without your written consent or authorization. Please note that, subject to applicable law, disclosed information may be subject to redisclosure by the recipient, and may no longer be considered to be protected health information pursuant to the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder.
_____________________________________ Signature of Client or Client’s Legal Representative
_____________________________________ Print Name
_____________________________________ Date
_____________________________________ Relationship (if signed by person other than client) FORM REVISED 8/2004; EFFECTIVE DATE 10/1/2004
FORM REVISED 8/2006; EFFECTIVE DATE 9/12/2006
CONSENTIMIENTO DE INSCRIPCION EN EL BANCO CENTRAL DE DATOS Y DE
PARTICIPACION EN EL PROGRAMA DE MANEJO DE CASOS
I. CONSENTIMIENTO DE INSCRIPCION EN EL BANCO CENTRAL DE DATOS
Yo, ( nombre del cliente) _____________________________________, doy mi consentimiento
para inscribirme en el banco central de datos de clientes establecido por la Fundación de SIDA de
Chicago (el “banco de datos”) para asistir y monitorear la inscripción de personas que reciben manejo de
caso y servicios directos a través de la Cooperativa de Manejo de Casos de VIH/SIDA del Noroeste de
Illinois (la “cooperativa).Yo entiendo que mi participación en el banco de datos depende de la finalización
de una forma separada y distinta de consentimiento para transferir mi información médica al banco de
datos.
En conexión con mi inscripción en el banco de datos, por este medio permito que la siguiente
información sea proporcionada a la Fundación de SIDA de Chicago para ser ingresada al banco de datos:
mi nombre, mi fecha de nacimiento, número de seguro social, el apellido de mi madre, cualquier estatus
de VIH positivo o negativo y otros datos demográficos. Yo entiendo que esta información va a ser
agrupada con la de otros clientes con el propósito de generar reportes estadísticos, evitar la duplicación
de servicios y coordinar el sistema de entrega de servicios a personas con o en alto riesgo de contraer el
VIH, sus familiares, y/o sus parejas y específicamente autorizo el uso de esta información para ese
propósito.
II. CONSENTIMIENTO DE PARTICIPACION EN EL PROGRAMA DE MANEJO DE CASOS
Yo, (nombre del cliente) ____________________________, doy mi consentimiento para
participar en el programa de manejo de casos (el “programa”) ofrecido por la Cooperativa de Manejo de
Casos de VIH/SIDA del Noroeste de Illinois (la “cooperativa”).
La cooperativa es una división de la Fundación de SIDA de Chicago, la cual es una organización
sin ánimo de lucro. La cooperativa asiste a personas con o sin la infección del VIH, sus dependientes, y
sus representantes legales a obtener servicios médicos y sociales los cuales pueden ser solicitados en
cualquier momento. Un buen número de agencias de servicio social trabajan con la cooperativa para
proveer una amplia variedad de servicios a cada cliente.
Los servicios de la cooperativa se ofrecen a personas con la infección del VIH, sus familiares, y/o
sus parejas, sin importar su capacidad para pagar. Cuando es apropiado, la cooperativa negocia con
compañías de seguros privadas y/o con el Departamento de Ayuda Pública de Illinois el pago por los
servicios.
Durante mi participación en el programa, mi manejador de casos y yo nos pondremos de acuerdo
sobre cuáles son mis necesidades médicas y sociales y esas necesidades serán tratadas a través de
referidos a la agencia o al sistema de servicios apropiados. Durante mi participación en el programa, mis
necesidades serán evaluadas regularmente para determinar cambios en el plan de servicios.
Yo continuaré participando en el programa y recibiendo los servicios de manejo de casos
ofrecidos por la cooperativa, a menos que yo escoja, en cualquier momento, rechazar los servicios o si soy
dado de alta de mi participación en el programa por una o más de las siguientes razones:
1. Si yo suspendo mi consentimiento para
proveer mi información a la Fundación.
2. No actuar en conformidad con mi plan de servicios (por ejemplo, no
comunicarme con mi manejador de casos asignado por tres meses o más)
3. Amenazar a algún empleado de la cooperativa o a otros con la probabilidad de
que voy a hacer efectivas mis amenazas; o
4. La existencia de problemas de seguridad ambiental que amenazan mi bienestar y
el de mi manejador de casos.
Si alguna de estas razones ocurre, yo entiendo que los servicios de manejo de casos me pueden
ser prohibidos o limitados.
Yo estoy de acuerdo en notificar a mi manejador de casos sobre cualquier cambio significativo en
mi estado (físico, mental, social, económico y otros) o si tengo la intención de cambiar mi participación
en el plan de cuidados desarrollado por mi en conexión con mi participación en el Programa.
_____________________________________
Firma del cliente o representante legal del cliente
_____________________________________
Nombre
_____________________________________
Fecha
_____________________________________
Parentesco (Si es firmada por otra persona que no es el
cliente)) FORM REVISED 8/2004; EFFECTIVE DATE 10/1/2004
FORM REVISED 6/2006; EFFECTIVE DATE __________
CONSENTIMIENTO PARA TRANSFERIR INFORMACION
Sujeto a las limitaciones y condiciones abajo expuestas, yo, ___________________por
medio de la presente, doy mi consentimiento a __________________________________
(“Proveedor/Manejador de Casos”), actuando a través de sus empleados o agentes, a usar y/o
revelar información sobre mi salud y mis archivos médicos a la Fundación de SIDA de Chicago,
la Cooperativa de Manejo de Casos de VIH/SIDA del Noroeste de Illinois (la “cooperativa”) y/o
cualquier agencia que provee servicios a través de la cooperativa (colectivamente, los
“destinatarios”), para lo siguiente: (i) en conexión con mi participación en el banco central de
datos establecido por la Fundación de SIDA de Chicago (el “banco de datos”) y el manejo del
mismo (ii) para permitir a la Fundación de SIDA de Chicago y a la Cooperativa conducir
programas que garanticen la calidad de los servicios para los individuos que reciben manejo de
casos a través de la cooperativa; (iii) para evitar duplicación de servicios en las agencias de
manejo de casos; y (iv) en conexión con el suministro de reportes y otros datos a las entidades
gubernamentales que proveen los fondos.
En conexión con mi inscripción en el banco de datos, a través de este medio, doy mi
consentimiento para que la siguiente información sea proporcionada a la Fundación de SIDA de
Chicago para ser ingresada al banco de datos: mi nombre, fecha de nacimiento, mi número de
seguro social, el apellido de mi madre, y otros datos demográficos. También entiendo que es mi
responsabilidad verificar mi condición con respeto al VIH, (si, aplica) y fechas de tratamiento
médico y servicio de manejo de casos que serán sometidos a la Fundación de SIDA de Chicago.
Entiendo que esta información va a ser agrupada con la de otros clientes con el propósito de
generar reportes estadísticos, evitar la duplicación de servicios y coordinar el sistema de entrega
de servicios a personas con VIH, sus familiares y/o sus parejas y específicamente autorizo el uso
de esta información para ese propósito.
Además yo permito a los empleados de la Fundación de SIDA de Chicago y a los comités
designados de la Cooperativa revisar mis archivos de servicios como parte del programa que
garantiza la calidad de servicios de la Cooperativa. Como propósito de este consentimiento, yo
reconozco y estoy de acuerdo en que mis archivos incluyen cualquier o todos los archivos
generados por cualquier agencia proveedora de servicios que forma parte de la Cooperativa.
Ninguna información que yo provea con el propósito de recibir servicios será
revelada a ninguna agencia gubernamental ni al departamento de salud con propósitos de
vigilancia, ubicación, o cualquier otro propósito que no sea obtener servicios médicos o
sociales, exceptuando (1) con mi consentimiento, (2) si es requerido por la ley, o (3) de ser
necesario, para prevenir una seria intención de ocasionar daño a otros o a mi mismo.
Precauciones de seguridad se mantendrán para prevenir el acceso no autorizado al banco
de datos por cualquier persona que no sea empleado de la Fundación de SIDA de Chicago.
Yo doy consentimiento adicional para reportar información que yo provea en connección
con el banco de datos y en connección con los servicios recibidos a través de fondos federales
que apoyan a la Fundación SIDA de Chicago. Entiendo que esta información puede ser sometida
en grupo o individualmente. Yo entiendo que, con el propósito de proteger mi privacidad, toda
información sometida en forma individual con excepción de los servicios patrocinados por Title
II, serán proveídos con codigos individuales sin nombre ni ninguna información que me
identifique.
Además, yo entiendo que si llego a recibir servicios bajo el Proyecto de ley Titulo II de
Ryan White, alguna información será reportada a la Unidad de Servicios Directos del
Departamento de Salud Pública de Illinois, incluyendo:
- información demográfica que incluye pero no esta limitada a mi nombre, sexo, raza,
número de seguro social, y fecha de nacimiento; información sobre servicios que he utilizado,
diagnostico de VIH/SIDA e información sobre mi tratamiento; información sobre servicios de
salud mental o uso de drogas será compartido con el propósito de evaluar servicios proveídos,
revisar archivos, o en casos donde el compartir información sea necesario para coordinar
servicios.
Yo puedo poner fin a este consentimiento presentando una solicitud por escrito a
cualquiera de los Destinatarios (Agencias en las cooperativas) indicando que ya no deseo recibir
servicios de la cooperativa o indicando mi revocación escrita a esta autorización.
Yo entiendo que puedo rehusarme a firmar este consentimiento. Yo además entiendo que
puedo suspender este consentimiento en cualquier momento presentando una nota por escrito al
proveedor de servicios con mi intención de suspender este consentimiento. Este consentimiento
no puede ser suspendido en la medida en que alguna acción ha sido tomada basada en este
consentimiento.
Este consentimiento es valido por el periodo de un año a partir de la fecha en que es
firmado por el cliente
El proveedor no usará o revelará información personal de salud más allá del propósito de esta autorización sin su autorización o consentimiento escrito. Por favor tenga en cuenta que, sujeto a la ley que aplica, la información revelada está sujeta a ser revelada a su vez por el que la recibe, y puede entonces no ser considerada información de salud protegida, en conformidad con al acta de transferibilidad y responsabilidad de seguro de salud de 1996 (HIPAA-Health Insurance Portability and Accountability Act of 1996) y las regulaciones promulgadas a partir de entonces.
_____________________________________ Firma del cliente o su representante legal
_____________________________________ Nombre
_____________________________________ Fecha
_____________________________________ Parentesco (Si es firmada por otra persona que no es el cliente)) FORM REVISED 8/2004; EFFECTIVE DATE 10/1/2004
FORM REVISED 6/2006; EFFECTIVE DATE ___________
CASE MANAGER GUIDE:
CONSENT TO ENROLL
AND
CONSENT TO RELEASE INFORMATION
FORMS
� These forms will become effective on September 12, 2006.
� These forms should be signed by all new clients after September 12th
, as well as
continuing clients as soon as possible and no later than at their next scheduled
reassessment. The clients’ signature should be noted in the reassessment workflow in
Factors.
By signing these forms I understand that:
� My service information (including name) will be reported to the Illinois Department
of Public Health’s Direct Services Unit for the SOLE purposes of reporting service
utilization;
� My information will be regarded with the highest privacy possible to ensure federal
reporting standards. AFC users will remain the same and only two people at IDPH (the
Consortia Coordinator and the Data Coordinator) will have access to the reported
information;
� My information will not be given out for surveillance or contact tracing purposes, but
will only be reported for the purposes of service utilization tracking;
� My information is used to obtain health care and social services;
� I can terminate services at any time with a written request;
� I have the right to refuse to sign this Authorization form; and
� I have the right to request a copy of this Authorization form
By signing these forms I give my permission to:
� Disclose my health information and case management records to the AIDS Foundation of
Chicago and the other cooperative agencies;
� Have my information entered into the central database for the purpose of:
� Statistical Reports
� Ensure there is no duplication of services
� Tracking service linkages and health status over time;
� Have my file reviewed by the AIDS Foundation of Chicago for quality assurance
purposes;
� Have my name (IDPH only) or unique coded identifier (all other funding sources),
service utilization information and limited demographic information sent to federal grants
programs that support the AIDS Foundation of Chicago.
CONSENT TO ENROLL IN THE CLIENT DATABASE AND PARTICIPATE IN CASE
MANAGEMENT SERVICES PROGRAM
AND
CONSENT TO RELEASE INFORMATION
The Consent to Enroll in the Client Database and Participate in Case Management Services Program and
the Consent to Release Information forms are to protect your confidentiality and ensure that your HIV
status, risk factors, or use of services are not released without your written/documented consent.
Your identifying information will only be released to parties outside of the Cooperative if required by law
or federal funding requirements or to prevent harm to yourself or others.
CONSENT TO ENROLL
You must sign this form before your information can be submitted to the AIDS Foundation of Chicago
(AFC) to be entered in the central database, and every year thereafter, to remain an active client. Your
information can not be submitted or re-submitted to AFC without your handwritten consent on this form
or the consent of a legal guardian.
This form only allows your Case Manager to verify your prior enrollment in the database. Due to this, at
the time of signing you can only receive referral, education and support information.
The Consent to Participate in Case Management Services form explains what is expected of you while
receiving case management services and explains the consequences of non-compliance, abuse, threats,
and other safety concerns.
CONSENT FOR RELEASE OF INFORMATION Your identifying information (name, date of birth, and HIV status) can not be collected without your
handwritten consent on the Consent for Release of Information form or the consent of a legal guardian.
You may choose not to sign the Consent for Release of Information. However, it is necessary that AFC
and your provider agency document your HIV status in order for you to receive services.
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 5A – Assessments: Acuity
Date: October 25, 2007 (Previously SOP 4) Revised: February 29, 2008 Page 1 of 28
PURPOSE: To set a minimum standard across Cooperative agencies regarding the frequency and duration of
client contact based on an assessment of client needs.
POLICY: Client acuity will be determined at intake, reassessment, and/or whenever substantial changes
occur in a client’s clinical and social needs.
Case managers will take a lead role to identify the appropriate level of services based on the
client need and as outlined in SOP 2: Determinants of Case Management Eligibility Level.
Regardless of the type of case management provided, three key elements of a case manager’s
role are: initially assessing the service needs of clients, developing a comprehensive,
individualized service plan with clients, and coordinating services required to implement the
plan. The attached acuity scale is a tool that has been developed to assist case managers in
completing these tasks. Additionally, case managers will play a key role in determining the
appropriate level of case management services, medical case management, or supportive services
case management. This acuity scale will help case managers begin to collect information to
assist in that determination.
PROCEDURE: Case managers will make periodic contact with clients to assess and monitor changing needs and
the utility of the service plan. Frequency and type of contact must be based on client’s acuity
score. Case managers will act as liaisons between clients and service providers to facilitate
implementation of the service plan. Case managers will provide supportive counseling and
encouragement to clients for whom appropriate services cannot be found or have yet to be
implemented.
The acuity scale is organized into two parts: social service and support needs assessment (Social
Determinants of Health Scale – Part 1) and medical and key core services needs assessment
(Clinical Acuity Scale- Part 2).
The Social Determinants of Health Scale evaluates the following areas: A)Legal; B) Basic
Living Needs; C) Transportation; D) Culture and Language; E) Social Support; F) Risk
Reduction; G) Housing and Residential Needs; H) Income & Finances and I) Family and
Dependents.
The Clinical Acuity Scale assesses: 1) Medical Care (access and adherence); 2) Mental Health
service needs 3) Substance Abuse service needs; and 4) Other Clinical Needs.
These forms are intended to be used in conjunction with the Client Intake/Case Status Change
and Reassessment tool to assist in gathering client assessment information at baseline, during
ongoing client assessments, and to collect and assess eligibility information. The client intake
form provides basic information which case managers should refer to when completing the
acuity tool. To be effective, both parts of the acuity scale must be administered during the same
session. In addition, the tools must be completed during a face-to-face encounter with the client
to assess client-identified needs in each of these areas. All information gathered during the acuity
assessment must be entered into the client-level database and should be utilized to create the
client’s service plan.
FORMS: Acuity Scale Instructions
Acuity Part 1 Social Determinants Scale
Acuity Part 2 Clinical Determinants Scale
Acuity Scale Instructions Part 1 Social Determinants of Health
This section of the acuity scale focuses on assessment of client social service needs. The
information is similar to the information that is collected at an intake assessment and/or
reassessment. Case managers should administer this section of the acuity scale prior to
administering the clinical indicators portion of the acuity scale (Part 2).
Administering the scale in this order will help case managers build strong working
relationships and help facilitate conversations with clients. It will also help case
managers identify acute social service needs of the client more quickly. Finally, case
managers are more familiar with assessing social services needs, which may be a more
comfortable format for both the case manager and client.
The scale identifies common key areas where clients may require traditional case
management supportive services. Information collected in these areas will help inform
individual service plans, but should not replace traditional agency service plans.
Administration
Case managers will analyze each social service area based on client response to the
general questions asked and the specific questions in specific sections. Case managers
will assign a level of service need per general area. The levels of service need
corresponding with highest level of need that the client identifies. For example, if a
client answers yes to a question for level 3, they are assigned a value for level 3. For
sections A- F, a specific question is provided which case managers should use as a guide
for asking clients. Case managers are free to use additional probing techniques to help
collect information to place the client in the appropriate level. Additional information to
help complete the acuity for Sections G-I can be answered based on the clients answers to
corresponding sections in the Client Intake/Case Status Change and Reassessment form.
The assessment should be administered in an informal conversational interview format.
For each section, there are a series of yes/no and open ended questions that correspond to
different levels of service need. Case managers are encouraged to ask these questions
and assign a score to the client based on the responses to the questions. Case managers
will utilize this information to develop a service plan that addresses client needs as
identified in the responses. Case manager clinical judgment and follow up questions to
the client are encouraged to help determine the level of service need per area.
The scale uses a point system to determine degree of need. Points are assigned by levels.
There are four levels that have the following point breakdown:
Level 1: 0 points
Level 2: 2 points
Level 3: 4 points
Level 4: 8 points
A cumulative score for part 1 is obtained by summing up the total points for each section.
QUESTION BY QUESTION GUIDE
Section A: Legal
This section focuses on any legal issues the client may be currently experiencing. Case
managers will want to collect information on past history of incarceration and what
specific need(s) a client may have in this area. The probe question is provided below:
Do you have any current or recent legal issues that require additional assistance (i.e. pending cases, powers of attorney, and living wills)? Do you have all the legal documents you need to care for yourself?
Also, it is important to refer to the legal section of the Client Intake/Case Status Change
and Reassessment form to help identify any recent incarcerations or pending court cases.
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section B: Basic Living Needs
Client basic needs and level of independent functioning are assessed in this section. This
section provides important information as to the client’s immediate food and shelter
needs.
Do you have basic living needs, such as clothes, food, etc? Can you perform activities that keep you independent in your home such as bathing, grooming, dressing, cooking, cleaning, etc?
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section C: Transportation
This section assesses the transportation needs. It is important to determine whether
transportation factors play a role in accessing medical care.
What type of transportation do you currently use to get to your primary care/medical and other clinical appointments, and have you experienced any gaps?
Page 4 of the Client Intake/Case Status Change and Reassessment form will help to
determine eligibility of the client to receive Ryan White funded transportation services.
This section of the acuity scale will help to determine the level of need for those services.
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section D: Culture and Language
This section assesses cultural or language barriers that may impact access to medical or
social services. Cultural barriers also include barriers clients may experience due to their
sexual orientation or religious beliefs.
Do you or your family have any language or cultural barriers that prevent you from identifying and accessing services?
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section E: Social Support System
This section focuses on client self-assessment of type and quality of social support that
the client receives from family, friends or professionals to help manage and cope with
their HIV. (Note: this question is different than section G which assesses their role
within their family and the dependents or family responsibilities they may have). This
section should also be used to identify any potential domestic violence issues facing the
client.
Please describe your family, friends, and loved ones and their ability to support you as you treat your HIV/AIDS. Are you currently experiencing any emotional or physical abuse from any of these individuals?
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section F: Risk Reduction
This section helps case managers begin to discuss risk reduction to better understand the
degree to which a client may be engaging in high risk behavior. When asking this
question it is important to indicate that the question pertains to a specific time period
(Past Month). Case managers should try to get client to quantify the frequency rather than
give simply a percentage.
For example, begin the question by stating “Within the last month…” When possible,
obtain actual number. For example, if the client states 20% of the time, clarify if that
corresponds with 1 unsafe sexual encounter out of five, or 2 unsafe sexual encounters out
ten. The acuity defines the 20% level as mild, > 20% to 50% as moderate, and over 50%
as significant. Any level of high risk sexual practices represents a need for education and
prevention counseling. These levels are designed to gauge the extent of the issue to be
addressed in the service plan.
How often have you engaged in any behaviors that put you at risk for re-infection of HIV, infection of another STD, or has put another person at risk for contracting HIV? How many times in the past year have you been diagnosed with an STD?
SECTIONS G THROUGH I
THE FOLLOWING SECTIONS ARE ADDITIONAL AREAS THAT CASE
MANAGERS MUST ASSESS. IN ORDER TO COMPLETE THE REMAINING
SECTIONS, IT IS NECESSARY TO REFER TO THE CLIENT’S INTAKE FORM AS
WELL AS THE QUESTIONS IN EACH LEVEL. EACH OF THE FOLLOWING
SECTIONS CORRESPOND TO AN IDENTIFIED DATA COLLECTION SECTION
OF THE CLIENT INTAKE/CASE STATUS CHANGE AND REASSESSMENT
FORM.
Section G: Housing and Residential Needs
This section relates to acute and long-term housing needs. Information on current living
arrangements is provided in Client Intake/Case Status Change and Reassessment form.
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section H: Income & Finances
This section assesses the client’s financial needs. This section assesses income sources
and need for additional benefit services to adequately support the client.
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section I: Family & Dependents
This section assesses whether the client has dependents or needs support to manage own
dependents. This section also focuses on the client’s responsibilities as a provider to
his/her own family.
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Instructions for obtaining an overall acuity rating for Part 1
The total acuity rating is the sum of scores for sections A to I. The range of scores will be
0 -72. The higher score should indicate the greatest need. After completing Part 1, case
managers must then administer Part 2 of the acuity scale, Clinical Indicators.
Part 2 Clinical Determinants of Health
This section of the acuity scale focuses on assessment of client clinical needs. The
information is a more in depth assessment of the basic clinical information that is
collected at an intake assessment and/or reassessment. Case managers should administer
this section of the acuity scale after administering the social determinants portion of the
acuity scale (Part 1).
The clinical indicators address the core services that are identified in the Ryan White
HIV/AIDS Treatment Modernization Act: medical care, substance use, mental health,
and oral health.
The scale identifies common key areas where clients may require case management
supportive services in order to establish or maintain adherence to key clinical treatments
in their HIV care. Information collected in these areas will help inform individual service
plans, but should not replace traditional agency service plans.
Administration
Case managers will analyze each clinical service area based on client response to the
general questions asked and the specific questions in specific sections. Case managers
will assign a level of service need per general area. The levels of service need
corresponding with highest level of need that the client identifies. For example, if a
client answers yes to a question for level 3, they are assigned the point value for level
three. Ideally, the assessment should be administered in an informal conversational
interview format.
For each section, there are a series of yes/no and open ended questions that correspond to
different levels of service need. Case managers are encouraged to ask these questions
and assign a score to the client based on the responses to the questions. Case managers
will utilize this information to develop a service plan that addresses client needs as
identified in the responses. Case manager clinical judgment and follow up questions to
the client are encouraged to help determine the level of service need per area.
The scale uses a point system to determine degree of need. Points are assigned by levels.
Most questions have four response levels that have the following point breakdown:
Level 1: 0 points
Level 2: 2 points
Level 3: 4 points
Level 4: 8 points
Some questions have a separate scoring format that is delineated on the forms and
throughout the instructions. A cumulative score for Part 2 is obtained by summing up the
total number of points for each section.
Section A: Medical Assessment (0 – 64 points)
This section of the clinical acuity scale is intended to assess the level to which a client is
enrolled and active in obtaining primary care and to assess any needs in this area. The
clinical acuity scale Medical Assessment section is divided into 2 subsections: (A1)
Access to Medical Care and (A2) HIV Medication Adherence. Section A1 assesses
whether a client currently has a medical care provider, the adherence to the most recent
medical visits, and frequency of missed appointments. Section A2 assesses the need for
and access to HIV medications. It also assesses the degree to which a client reports being
adherent to their HIV medication regiment for those clients currently prescribed and
taking HIV medications.
Section A1: Access to Medical Care
A1a: Do you currently have a stable medical provider (Doctor, Nurse, etc) who you see for your HIV treatment?
This is a yes/no question. If client responds “no,” you will automatically assign a score
of 64 and move on to Section B (Mental Health Assessment). The rationale for assigning
a score of 64 (the maximum number of points) relates to HIV being a chronic medical
condition requiring on-going primary medical care monitoring, so clients with no primary
medical care currently should receive ongoing HIV medical care to monitor their HIV
disease, slow its progression, and manage HIV related symptoms. Case managers should
work with the client to coordinate a medical appointment within the 2 weeks following
this assessment.
If the client responds “yes,” move on to questions A1b and A1c. A “yes” response to
question A1a is not assigned a point value. Case managers should work with the client to
coordinate and monitor medical appointments.
A1b: When did you last see your medical provider?
There are four categories that a client can select:
Within the last three months (Level 1 = 0 points)
Between three and six months ago (Level 2 = 2 points)
Between six months and one year (Level 3 = 4 points)
More than one year ago (Level 4 = 8 points)
A point score, ranging from 0 to 8, is assigned based on the client response.
This follow-up question to A1a, along with question A1c, provides the case manager with
pertinent information as to whether the client is seeing an HIV medical provider
regularly.
If the client scores zero points, skip to question A2a.
A1c: How many of the last three doctor’s appointments did you miss excluding the most recent appointment kept?
There are 4 responses a client can select from:
None (Level 1 = 0 points)
One (Level 2 = 2 points)
Two (Level 3 = 4 points)
Three (Level 4 = 8 points)
NOTE: The frequency that a client should see their HIV medical provider depends on
their health status (e.g. viral load levels, acute medical conditions) and current Public
Health system treatment guidelines. The categories provided in the question are not
intended to make any clinical assessment, but rather to provide case managers with a
general indication of treatment adherence to determine need for primary care referrals.
Section A2: HIV Medications and Treatment
This section is intended to assess the degree to which clients who are being prescribed
medications report being adherent to their prescribed HIV medication regimens.
Responses in this section are weighted differently than the other sections for two reasons.
First, medication adherence is an extremely important component of their overall medical
care. Second, medication adherence is best viewed as a yes/no type of assessment. A
client is either taking their HIV medication regularly or they are not, the degree of non-
adherence is less important than the reasons for the non-adherence.
A2a: Have you been prescribed medications for your HIV?
This is a yes/no question and is not scored. Further information is needed to find out
whether the client is not taking medication for “clinically appropriate” reasons or other
reasons. If a client says “no,” ask question A2b. If a client responds “yes,” go to
question A2c.
A2b: Why are you currently not prescribed medications for your HIV?
There are 4 responses a client can select from:
Medical Provider says I do not need to be (Level 1 =0 points)
Medical Provider took me off my meds, or is assessing readiness (Level 2 =2 points)
I cannot get access to payment for the medications (Level 3 =6 points)*
I don’t want to be on medications (Level 4 =10 points)*
*(Since medication access and non-adherence is such an important treatment component,
lack of access to HIV medication or resistance to taking medication is scored at a higher
level.)
For those client’s determined to be prescribed medications, the case manager must than
administer questions A2c-A2e to assess the client’s medication adherence. Assign point
values based on client’s responses to determine the degree of adherence.
A2c: How often do you feel that you have difficulty taking your HIV medications on time? (By “on time” we mean no more than two hours before or after the time your doctor told you to take it.)
Never (Level 1 = 0 pts)
Rarely (Level 2 = 2 pts)
Most of the time (Level 3 = 4 pts)
All of the time (Level 4 = 8 pts)
If a client has difficulty quantifying this, ask them to give you their best guess, or respond
with the first response that comes to their head. Remind them that the goal is to
support adherence, not penalize non-adherence.
A2d: On average, how many days PER WEEK would you say that you missed at least one dose of your HIV medications?
Never (Level 1 = 0 pts)
1 – 3 days per week (Level 2 = 2 pts)
4 – 6 days per week (Level 3 = 4 pts)
Every day (Level 4 = 8 pts)
A2e: When was the last time you missed at lest one dose of your HIV medications?
Never (Level 1 = 0 pts)
More than two weeks ago (Level 2 = 2 pts)
1 – 2 weeks ago (Level 3 = 4 pts)
Within the past week (Level 4 = 8 pts)
HOW TO SCORE SECTION A
Scores from section A1 and A2 are summed together to get an overall score for the
medical assessment section. Scores can range from 0 to 64. The higher the score the
greater the need to work with the client to ensure that they enter and remain connected
with a medical care provider. In service planning, any area with a score of 4 or higher
should be addressed with an objective in the service plan. For example, if the client
indicates that they have missed doses 4 – 6 days in the last two weeks (a score of 4), as
measured in question A2d, the case manager should probe further to reduce the barriers
to adherence for this client.
Section B: Mental Health Assessment (0 -40 points)
The purpose of this section is to: 1) assess level of emotional distress (mental health
symptoms) client is currently experiencing; 2) whether that distress is affecting their
ability to maintain medical care and 3) to decide whether referral to mental health
services is needed.
The clinical acuity scale Mental Health Assessment section is divided into 2 subsections:
(B1) Access to Mental Health Care and (B2) Psychiatric Medication Adherence. Section
B1 assesses whether a client currently has a mental health issue and, if the client currently
has a mental health provider, the adherence to the most recent treatment visits, and
frequency of missed appointments. Section B2 assesses the need for and access to
psychiatric medications. It also assesses the degree to which a client reports being
adherent to their medication regiment for those clients currently prescribed and taking
psychiatric medications.
Section B1: Access to Mental Health Care
B1a: Has your mental or emotional health ever affected your ability to complete your activities of daily living?
This is a yes/no question. If client responds “no,” a score of zero is recorded and you
skip to Section C Substance Use Assessment. If a client reports “yes,” a score of 8 is
assigned to this question.
B1b: Have you ever been treated for mental illness?
This question is not assigned a point value. It just provides information that may be used
for service planning. For example, a client may report no emotional distress which may
be due to them seeing a mental health provider. It also seeks to predict future activities to
treat mental illness, by assessing past treatment seeking behaviors.
B1c: Do you currently have a counselor/psychiatrist/therapist that you see for your mental health treatment?
If the client responds “yes,” ask question B1d. This question is not scored.
B1d: How many of the last three doctor’s appointments did you miss excluding the most recent appointment kept?
There are 4 responses a client can select from:
None (Level 1 = 0 points)
One (Level 2 = 2 points)
Two (Level 3 = 4 points)
Three (Level 4 = 8 points)
This question helps assess the degree of engagement in mental health care. It may be
helpful to do some probing to find out why a client may not be seeing a clinician
regularly, if determined that the client is experiencing mental or emotional disruptions.
Section B2: Psychiatric Medication
B2a: Are you currently being prescribed medications for your mental illness?
This is a yes/no question and is not scored. If “no,” skip to Section C Substance Use
Assessment.
For clients who are being prescribed medications, the case manager must than administer
questions B2b-B2d to assess the client’s medication adherence. Assign point values based
on client’s responses to determine the degree of adherence.
B2b: How often do you feel that you have difficulty taking your mental illness medications on time? (By “on time” we mean no more than two hours before or after the time your doctor told you to take it.)
Never (Level 1 = 0 pts)
Rarely (Level 2 = 2 pts)
Most of the time (Level 3 = 4 pts)
All of the time (Level 4 = 8 pts)
If a client has difficulty quantifying this, ask them to give you their best guess, or respond
with the first response that comes to their head. Remind them that the goal is to
support adherence, not penalize non-adherence.
B2c: On average, how many days PER WEEK would you say that you missed at least one dose of your medications?
Never (Level 1 = 0 pts)
1 – 3 days per week (Level 2 = 2 pts)
4 – 6 days per week (Level 3 = 4 pts)
Every day (Level 4 = 8 pts)
B2d: When was the last time you missed at least one dose of your mental illness medications?
Never (Level 1 = 0 pts)
More than two weeks ago (Level 2 = 2 pts)
1 – 2 weeks ago (Level 3 = 4 pts)
Within the past week (Level 4 = 8 pts)
HOW TO SCORE SECTION B
The maximum point score for this section is 40. Sum together scores from section B1 and
B2 for a total score. Case managers should also refer back to the client intake to help
inform service planning. The higher the score the greater the need to work with the client
to ensure that they enter and remain connected with a mental health care provider. In
service planning, any area with a score of 4 or higher should be addressed with an
objective in the service plan.
Note: There is some redundancy in client intake form and mental health assessment scale.
These tools should be used in conjunction to inform the service plan.
Section C: Substance Use Assessment (0 – 40 points)
This section requires that you use information from both the substance use section of the
client intake form and the questions asked here about substance use treatment history.
Together this information will help you decide whether a substance use treatment referral
is needed and provide information about the impact of substance use on a client’s life.
The clinical acuity scale Substance Use Assessment section is divided into 2 subsections:
(C1) Access to Substance Use Treatment and (C2) Substance Use Medications and
Treatment Adherence. Section C1 assesses whether a client currently has a substance use
issue and, if the client currently has a treatment provider, the adherence to the most recent
treatment visits, and frequency of missed appointments. Section C2 assesses the need
for and access to substance use medications and treatments. It also assesses the degree to
which a client reports being adherent to their medication regiment for those clients
currently prescribed and taking methadone or other medications.
Section C1: Substance Use Access to Care
C1a: Are you currently being treated for substance use?
This is a yes/no question. If “no,” skip to Section D Other Clinical Needs. If “yes,”
continue to question C1B. This information can be compared to the substance pattern
questionnaire from the Intake/Case Status form to help inform whether or not the client
has an historical or existing substance use issue.
C1b: If yes, what type of treatment are you receiving?
This question will help you determine the degree of substance use severity and level of
support the client is seeking to address. Clients referred to more intensive substance use
treatment settings usually will require more intensive and ongoing treatment. They also
may be at high risk for medical treatment non-adherence.
Self-Help, 12-step (Level 1 = 0 pts)
Outpatient Treatment (Level 2 = 2pts)
Day Treatment (Level 3 = 4pts)
Residential (Level 4 = 8pts)
C1c: Do you currently have a stable counselor/therapist who you see for your substance use treatment?
If the client responds “yes,” ask question C1d. This question is not scored.
C1d: How many of the last three counselor/therapist’s appointments did you miss?
There are 4 responses a client can select from:
None (Level 1 = 0 points)
One (Level 2 = 2 points)
Two (Level 3 = 4 points)
Three (Level 4 = 8 points)
This question helps assess the degree of engagement in substance use treatment. It may
be helpful to do some probing to find out “why” a client may not be accessing their
treatment regularly. This will be helpful for individual service planning.
Section C2: Substance Use Medications and Treatment
C2a: Have you been prescribed medications (methadone, etc.) for your substance use?
This is a yes/no question, and is most applicable to those with past or present opiate
addiction.
C2b: Have you missed any doses of your medication because you could not afford them or get them in any way?
This is a yes/no question. A yes response is scored as 8 points, and may indicate a
current need for treatment with barriers to accessing it.
HOW TO SCORE SECTION C
Sum the total responses to each section. The higher the score the greater the need to
work with the client to ensure that they enter and remain connected with a substance use
treatment provider. In service planning, any area with a score of 4 or higher should be
addressed with an objective in the service plan.
Section D: Other Clinical Needs (0 – 40 points)
The information collected will help assess need for medical case management and
informs individual treatment planning. The format for this section is different than
Sections A-C as there is only one question per the five domains. In this section, it is
important to assign a score for each section based on the highest level the client responds
to.
For each section, a general question is asked. The case manager is then provided with
some examples of responses that would be appropriate for various levels and points to
assign. Based on the response given, the case manager must make a clinical judgment
about the appropriate level of need and assign that point value.
Section D1: Knowledge of HIV Disease
This section is intended to help case managers get an estimate of the client’s HIV
knowledge level. Based on clients’ responses, case managers should assign a score
ranging from 0 to 8 for this section.
Level 1 (0 points): Client is able to describe to their case manager: 1) that HIV/AIDS is a
chronic illness; 2) requires ongoing medical care; and 3) there are available medical
treatments that keep people with HIV/AIDS living longer.
Case managers should ask these questions
� Can you tell me what CD4 T-cell count and viral load mean?
� Why is important to know and monitor your T-cell and viral load count?
� Can you tell me what “highly active antiretroviral therapy” (HAART)?
If a client answers these questions correctly, score client as 0 in the domain.
Level 2 (2 points): Client knows that s/he has a medical condition, but knows little about
how the virus affects the body. S/he also displays limited knowledge about medical
treatment. The client will not be able to clearly answer the level 1 questions, but does
demonstrate a basic understanding of HIV disease.
Case managers should ask these questions:
� Do you feel your general knowledge of HIV disease is good enough that you do
not need additional information? (y/n)
� Do you feel that you have a good understanding of the different types of HIV
medications regimens? (y/n)
If clients respond no, to either question, score as a 2.
Level 3 (4 points): Client communicated inaccurate information about HIV disease
progression. S/he is unaware how effective HIV medications can be for ongoing medical
care.
Case managers should ask these questions:
� Has anyone ever talked to you about HIV medications and how effective they are
in keeping you healthy? (y/n)
� Do you think that because you are HIV+ positive there is no treatment that can
help you? (y/n)
� Consider asking a true or false question from HIV educational materials you may
have available at your agency.
If a client responds no or continues to demonstrate inaccurate understanding, score as a 3.
Level 4 (8 points): Clients is unable to answer the basic information about HIV disease
(how HIV is transmitted, what HIV stands for, what AIDS stands for, etc.) Client does
not know how they contracted HIV or how it spreads. Client exhibits no knowledge of
HIV.
Section D2: Nutrition
This section assesses the need for nutritional services. The primary indicators are client
self- reported physical symptoms associated with eating and digestion that interferes with
day to day functioning (and potentially medication adherence).
Are you having any problems with eating, weight gain, abdominal pain, nausea or diarrhea? How often do you eat? How do your prepare food? Describe a general day’s eating habits. How do you manage nausea or diarrhea? Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section D3: Oral Health
This section assesses the need for dental services. The primary indicator is level of pain
client is experiencing and degree to which pain interferes with day to day functioning.
The questioning should also address any denture needs or problems.
Are you having any problems with you mouth or teeth, pain when chewing or eating, or have need for assistance with dentures?
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section D4: Health Insurance & Medical Coverage
Please remember to also review client responses from the Client Intake/Case Status
Change and Reassessment forms prior to completing this section.
How are you currently paying for your medical services and/or how are you paying for your medications? (Please refer to insurance and health coverage questions on Intake.)
Based on the client’s responses, case manager should assign level/point value and record
the score to the right of the category.
Section D5: Pregnancy
The final section pertains to reproductive health. It is to be asked to both men and
women. Case managers should adjust the wording of the question accordingly. That is,
if asking the question is to a male, the question should be directed to determine if the
client and his partner are currently pregnant or is planning to become pregnant.
Are you currently or planning to become pregnant? If you are pregnant, was this a planned pregnancy? Are you currently receiving prenatal care? The scoring must take into account the current pregnancy status, future reproductive
planning, and access to prenatal care.
HOW TO SCORE SECTION D
This section should be scored by summing the total of each section to obtain an overall
score for section D for a total possible score of 40 points. The higher the score the greater
the need to work with the client to ensure that these issues do not create barriers to
clinical care. In service planning, any area with a score of 4 or higher should be
addressed with an objective in the service plan.
Instructions for obtaining an overall acuity rating for Part 2 Clinical Indicators
The total acuity rating is the sum of scores for sections A through D. In prioritizing
categories of need, scores in the clinical acuity scale should be addressed prior to the
needs identified in the social determinants of health acuity tool, whenever possible.
Social determinants that are identified as barriers to accessing clinical care should also be
prioritized.
AIDS Foundation of Chicago Acuity Scale Part 1 – Social Determinants of Health
Client Name_______________________ Date of Assessment _____/_____/______ Date of Next Assessment _____/_____/______ AGENCY ___________________________
Social Determinants of Health Acuity Scale For sections A-E of the social determinants of health, assess the client’s need based on his/her answer to the following questions
Area Level 1 0 POINTS
Level 2 2 POINTS
Level 3 4 POINTS
Level 4 8 POINTS
Level/ Points
Do you have any current or recent legal issues that require additional assistance (i.e. pending cases, powers of attorney, and living wills)? Do you have all the legal documents you need to care for yourself? (Refer to the LEGAL section of the Intake/Case Status Change Form)
A: Legal
□ No past, recent, or current legal problems
□ All legal documents client desires are completed
□ Client has a living will and power of attorney documents
□ Possible recent or current legal problems needing monitoring
□ Wants assistance completing standard legal documents
□ Present involvement in civil or criminal matters
□ Unaware of standard legal documents which may be necessary
□ Incarcerated □ Immediate crisis
involving legal matters e.g. legal altercation with landlord/ employers, civil & criminal matters, immigration and/or family/DCFS
�
Do you have basic living needs, such as clothes, food, etc? Can you perform activities that keep you independent in your home such as bathing, grooming, dressing, cooking, cleaning, etc?
B: Basic Living Needs
□ Food, clothing and other basic needs met through client’s own means
□ Has ongoing access to assistance programs that maintain basic needs consistently
□ Able to perform activities of daily living (ADL) independently
□ Food, clothing, and basic needs met on a regular basis with collateral support
□ Occasional need for help accessing assistance programs
□ Unable to routinely meet basic needs without occasional emergency assistance
□ Needs weekly assistance to perform some ADLs
□ Often w/o food, clothing or other basic needs
□ Routinely needs help accessing assistance programs for basic needs
□ History of difficulties in accessing assistance programs on own
□ Needs in-home ADL assistance daily
□ Has no access to food or clothing
□ Without most basic needs
□ Unable to perform most ADL
□ No home to receive assistance with ADL
�
Area Level 1 0 POINTS
Level 2 2 POINTS
Level 3 4 POINTS
Level 4 8 POINTS
Level/ Points
What type of transportation do you currently use to get to your primary care/medical and other clinical appointments, and have you experienced any gaps?
C: Transpor-
tation
□ Has own or other means of transportation consistently available
□ Can drive self □ Can afford & use
private or public transportation
□ Has access to private transportation less than 50% of need
□ Needs occasional assistance with finances for transportation
□ Occasionally uses taxis funded by Ryan White for medical transportation
□ No means via self/others □ In area that lacks or is
underserved by public transportation
□ Unaware of available resources
□ Often requires taxis funded by Ryan White for medical transportation
□ Lack of transportation is a serious barrier to accessing care
□ Lack of transportation is a serious contributing factor to lack of regular medical care
�
Do you or your family have any language or cultural barriers that prevent you from identifying and accessing services?
D: Culture & Language
□ Client reports that language is not a barrier to accessing services (including sign language)
□ No cultural barriers to accessing services
□ Client will benefit from culturally appropriate interpretation services to access clinical services
□ Mild cultural barriers exist to accessing services
□ Family needs basic education and/or interpretation to provide support to the client
□ Culturally appropriate interpretation services are necessary for client to access clinical services
□ Family needs moderate education and/or interpretation to provide support to the client
□ Moderate cultural barriers exist to accessing services
□ Cultural factors significantly impair client ’s ability to access services
□ Family needs intensive education and/or interpretation to support the client
□ Severe cultural barriers exist to accessing services
�
Area Level 1 0 POINTS
Level 2 2 POINTS
Level 3 4 POINTS
Level 4 8 POINTS
Please describe your family, friends, and love ones and their ability to support you as you treat your HIV/AIDS. Are you currently experiencing any emotional or physical abuse from any of these individuals?
E: Social
Support Systems
□ Client identifies no domestic violence issues
□ Stable/dependable emotional/physical availability of social supports
□ Stable, consistent support for HIV/AIDS treatment
□ Gaps in support system □ Family and/or significant
others often unavailable □ Inconsistent support
when crises occur □ Inconsistent support for
HIV/AIDS treatment
□ No stable support system accessible
□ Only support is provided by professional caregivers
□ Minimal support for HIV/AIDS treatment
□ Client identifies potential domestic violence issues
□ Acute situation where client is unable to cope without professional support
□ No support available for HIV/AIDS treatment available
�
How often have do you engaged in any behaviors that put you at risk for re-infection of HIV, infection of another STI, or has put another person at risk for contracting HIV? How many times in the past year have you been diagnosed with an STI?
F: Risk
Reduction
□ Client is abstaining from risky behavior by safer practices
□ Client has excellent understanding of risks
□ Client with no relationship barriers to safe behavior
□ No documented STIs
□ Occasional risk behavior (unsafe behaviors of any type <=20% of the time)
□ Client has good understanding of risks
□ Client has mild relationship barriers to safe behavior
□ Has had one reported STIs in the past year.
□ Moderate risk behavior (unsafe behaviors of any type >20-50% of the time)
□ Client has poor understanding of risks
□ Client has moderate relationship barriers to safe behavior
□ Has had 2-3 reported STIs in the past year.
□ Significant risk behavior (unsafe behaviors of any type >50% of the time)
□ Client has little or no understanding of risks
□ Client has significant relationship barriers to safer behavior
□ Has had more than 3 reported STIs in the past year or is currently diagnosed
□ Declines to answer
�
Area Level 1 0 POINTS
Level 2 2 POINTS
Level 3 4 POINTS
Level 4 8 POINTS
Level/ Points
(Refer to the LIVING ARRANGEMENT CURRENT TYPE section of the Intake/Case Status Change Form)
G: Housing & Residential
Needs
□ Stable housing such as own rental unit or home ownership
□ Stable residential setting; not in jeopardy
□ Client has phone, consistent contact
□ Living in stable subsidized housing (public housing, private subsidized housing or secure Section-8 voucher, SRO)
□ Safe and secure non-subsidized housing, but choices limited due to moderate income
□ Client has phone, consistent contact
□ Living in long-term (>3 mo.) transitional rental housing (including group or foster home)
□ Formerly independent, temporarily residing with family/friends
□ Living in temporary transitional living (shelter, hotel/motel, institution)
□ Client has no phone, inconsistent contact
□ Client identifies needs for assistance with rent/utilities to maintain housing; housing is in jeopardy due to finance
□ Homeless, (living in emergency shelter, car, street, etc.)
□ Recently evicted from rental or residential program
□ No phone, no contact
□ Requests assisted living facility; unable to live independently
�
(Refer to the INCOME SOURCES section of the Intake/Case Status Change Form)
H: Income & Finances
□ Identified steady source of income – which is not in jeopardy
□ Client has savings/resources
□ Client able to meet monthly obligations
□ No identified need for financial planning or counseling
□ Has steady source income, but it’s short term or unstable
□ Client identified occasional need for financial assistance or awaiting outcome of benefits application
□ Client requested information about finance benefits
□ Minimal, unstable income that is often insufficient to meet expenses
□ Benefits denied □ Client needs assistance
with application process □ Client requests financial
planning & counseling
□ No Income □ Immediate need for
emergency financial assistance
□ Client requests a referral to representative payee
�
(Refer to the INFORMAL SUPPORTS section of the Intake/Case Status Change Form)
I: Family &
Dependents
□ Client identifies no dependents
□ Have stable relationships with dependents, no permanency planning needed
□ Client identifies unstable relationships with family
□ Client requests information regarding permanency planning and/or legal/family counseling
□ Client identifies occasional child care/ respite needs
□ Client requests referral for permanency planning and/or family counseling
□ Client requests ongoing child care/day care needs
□ Client requests access to parenting classes
□ Client identifies moderate needs regarding disclosure to family, dependents
□ Involvement with DHS/DCFS
□ Crisis related to family/dependents
□ Client identified runaway children
□ Dependent is danger to self and others
□ Non-disclosure of HIV to family is a barrier to care
�
Total Points A: Legal 0 – 8 points
Total Points B: Basic Living Needs 0 – 8 points Total Points C: Transportation 0 – 8 points
Total Points D: Culture & Language 0 – 8 points Total Points E: Social Support Systems 0 – 8 points
Total Points F: Risk Reduction 0 – 8 points Total Points G: Housing & Residential Needs 0 – 8 points
Total Points H: Income & Finances 0 – 8 points Total Points I: Family & Dependents 0 – 8 points
Total Points
TOTAL SOCIAL ACUITY SCALE SCORE (0 – 72 points)
AIDS Foundation of Chicago Acuity Scale Part 2 – Clinical Indicators Client Name_______________________ Date of Assessment _____/_____/______ Date of Next Assessment _____/_____/______
Agency _____________________________________________________________________________________________
Part A: MEDICAL ASSESSMENT (0-64 points) Area Level 1
0 POINTS Level 2
2 POINTS Level 3
4 POINTS Level 4
8 POINTS Level/ Points
Comments
A1a: Do you currently have a stable medical provider (Doctor, Nurse, etc.) who you see for your HIV treatment? Yes
No (Score at 64, and go to Part B) �
A1b: When did you last see your medical provider?
A1: Medical
Care Access to
Care
Within the last three months (skip to A2a)
Between three and six months ago
Between six months and one year
More than one year ago �
A1c: How many of the last three medical provider appointments did you miss, excluding the last appointment you kept?
None One Two Three
�
A2a: Are you currently being prescribed medications for your HIV?
Yes (Go to A2c) No
A2b: Why are you currently not prescribed HIV medications? (Answer, then skip to B1a) Medical Provider says I do not need to be
Medical Provider took me off my meds, or is assessing readiness
I cannot get access to payment for the medications (score = 6)
I don’t want to be on medications (score = 10)
�
A2c: How often do you feel that you have difficulty taking your HIV medications on time? (By “on time” we mean no more than two hours before or after the time your doctor told you to take it.)
A2: Medical
Care Medication
s and Treatment
Never Rarely Most of the time All of the time �
A2d: On average, how many days PER WEEK would you say that you missed at least one dose of your HIV medications? Never 1-3 days per week 4-6 days per week Every day
�
A2e: When was the last time you missed at least one dose of your HIV medications?
Never
More than two weeks ago
1-2 weeks ago Within the past week �
Part B: Mental Health Assessment (0 – 40 points)
Area Level 1 0 POINTS
Level 2 2 POINTS
Level 3 4 POINTS
Level 4 8 POINTS
Level/ Points
Comments
B1a: Has your mental or emotional health ever affected your ability to do your activities of daily living? No Yes
�
B1b: Have you ever been treated for a mental illness? No (Please skip to section C)
Yes
B1c: Do you currently have a counselor/psychiatrist/therapist who you see for your mental health treatment?
B1: Mental Health
Access to Care
Yes
No
B1e: How many of the last three doctor/therapist’s appointments did you miss?
None One
Two Three �
B2a: Are you currently being prescribed medications for your mental illness? Yes No (please skip to
section C)
B2b: How often do you feel that you have difficulty taking your mental illness medications on time? (By “on time” we mean no more than two hours before or after the time your doctor told you to take it.)
B2: Mental Health
Medications and
Treatment Never Rarely Most of the time All of the time
�
B2c: On average, how many days PER WEEK would you say that you missed at least one dose of your medications? Never 1-3 days per week
3-6 days per week Every day
�
B2d: When was the last time you missed at least one dose of your mental illness medications?
Never
More than 2 weeks ago 1-2 weeks ago Within the past week �
Part C: Substance Use Assessment (0 – 40 points) Area Level 1
0 POINTS Level 2
2 POINTS Level 3
4 POINTS Level 4
8 POINTS Level/ Points
Comments
C1a: Are you currently being treated for substance use? No (Please skip to section D)
Yes �
C1b: If Yes, what type of treatment are you receiving? Self-Help, 12 –Step, AA/NA
Outpatient Treatment Day Treatment (Intensive)
Residential treatment, Detox �
C1c: Do you currently have a stable counselor/therapist who you see for your substance use treatment?
C1: Substance
Use Access to
Care Yes
No
C1d: How many of the last three counselor/therapist’s appointments did you miss?
None One
Two Three �
C2a: Have you been prescribed medications (methadone, etc.) for your substance use? No (please skip to section D)
Yes �
C2b: Have you missed any doses of your medication because you could not afford them or get them in any way?
C2: Substance
Use Medication
s and Treatment
No Yes �
Part D: Other Clinical Needs Area Level 1
0 POINTS Level 2
2 POINTS Level 3
4 POINTS Level 4
8 POINTS Level/ Points
Comments
Is the client able to clearly explain to you: what do CD4 and viral load counts mean, how HIV affects their body, and what are their treatment options?
D1: Knowledge
of HIV Disease & Treatment
□ Verbalizes clear, comprehensive understanding about HIV disease
□ Understands all
medications
□ Verbalizes basic/minimal understanding of HIV disease
□ Needs additional information in some areas
□ Understands most medications
□ Verbalizes little understanding of HIV disease
□ Needs counseling or referral to make informed decisions about health
□ Minimal understanding of medications
□ No understanding of HIV disease progression, etc.
□ Unable to make informed decisions about health
□ Does not understand medications
�
Are you having any problems with eating, weight gain, abdominal pain, nausea or diarrhea?
D2: Nutrition
□ No abdominal pain reported
□ No significant weight problems
□ No problems with eating/access to food
□ No problems with nausea or vomiting
□ No nutritional intervention needs
□ Unplanned weight loss in the past 3 months
□ Requests assistance in improving nutrition
□ Occasional diarrhea
□ Client reports wasting syndrome or other obvious physical maladies
□ Abdominal problems reported that don’t disrupt daily activity
□ Nausea and/or vomiting reported that doesn’t disrupt daily activity
□ Chronic diarrhea reported that doesn’t disrupt daily activity
□ Client reports significant wasting syndrome or other physical maladies
□ Significant weight loss in past 3 months (more than 30% ideal body weight)
□ Chronic abdominal pain reported that disrupts daily activity
□ Severe problems eating
□ Chronic nausea and/or vomiting reported that disrupt daily activity
□ Chronic diarrhea reported that disrupts daily activity
�
Part D: Other Clinical Needs (continued)
Area Level 1 0 POINTS
Level 2 2 POINTS
Level 3 4 POINTS
Level 4 8 POINTS
Level/ Points
Comments
Are you having any problems with your mouth or teeth, pain when chewing or eating, or have need for assistance with dentures?
D3: Oral Health
□ No dental problems □ No pain with
chewing or eating □ Teeth/Dentures
have been assessed by dentist in past 6 months
□ Dental issues (gingivitis, small cavities), that do not disrupt daily activities
□ No pain with chewing or eating
□ Teeth/Dentures have been assessed by dentist in past 7-12 months.
□ Dental issues (large cavities, ill fitting dentures) that disrupt daily activities
□ Mild or occasional discomfort when chewing or eating
□ Teeth/Dentures have been assessed by dentist 1 – 2 yr.
□ Persistent dental issues that disrupt daily activities
□ Dental pain, possible dental infection
□ Immediate dental referral required
□ Teeth/Dentures have not been assessed by a dentist > 2 yr.
�
How are you currently paying for your medical services and/or how are you paying for your medications? (Please refer to insurance and health coverage questions on Intake)
D4: Health
Insurance & Medical Coverage
□ Insured /has medical care coverage
□ Has ability to pay for care - insurance and medications - on own
□ Assistance needed in accessing insurance or other coverage for medical costs (such as prescription drug coverage). No medical crisis.
□ Client needs information and guidance accessing insurance or other coverage for medical costs
□ Concerns with ability to pay for prescriptions, deductibles, and other out-of-pockets.
□ Needs Medicaid □ Needs MEPD □ Needs Medicare □ Needs connection
to publicly funded clinic
□ Needs IL ADAP
□ Needs immediate assistance in accessing insurance or other coverage for medical costs due to medical crisis
□ Not currently eligible for insurance or public benefits. Unable to access care
�
Are you or your partner currently pregnant or planning to become pregnant? If yes, was this a planned pregnancy? Are you or your partner currently receiving prenatal care?
D5: Pregnancy
□ Client/partner is not pregnant
□ Client/partner has planned pregnancy and is active in prenatal care
□ Client/partner is not pregnant, but requests more information about safe pregnancies for HIV+ women
□ Client/partner has a planned pregnancy but is not currently enrolled in prenatal care
□ Client/partner has an unplanned pregnancy and is not enrolled in prenatal care
�
Total Points Part A1: Primary Care Access to Care
Total Points Part A2: Primary Care Medications and Treatment
0 – 64 points
Total Points Part B1: Mental Health Access to Care
Total Points Part B2: Mental Health Medications and Treatment
0 – 40 points
Total Points Part C1: Substance Use Access to Care
Total Points Part C2: Substance Use Medications and Treatment
0 – 40 points
Total Points Part D1: Knowledge of HIV Disease & Treatment
0 – 8 points
Total Points Part D2: Nutrition
0 – 8 points
Total Points Part D3: Oral Health
0 – 8 points
Total Points Part D4: Health Insurance & Medical Coverage
0 – 8 points
Total Points Part D5: Pregnancy
0 – 8 points
TOTAL ACUITY SCALE SCORE (0 – 184 points)
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 5B – Assessments: Medical Assessment
Date: September 18, 2007 Revised: February 29, 2008 Page 1 of 3
PURPOSE: To set a minimum requirement for the collection of basic medical indicators on each client by
their respective case managers.
POLICY: Client medical eligibility will be determined at intake from client and primary care provider
reported information. Medical information will subsequently be collected at bi-annual intervals
(6 month reassessment) to assess ongoing medical indicators and client primary care needs.
PROCEDURE: All AFC-funded case managers will be required to facilitate the completion of the medical
information/primary care form as a part of the client intake and the reassessment at 6-month
intervals. The case manager is required to complete the demographics section of the Medical
Assessment form and send it to the physician or Cooperative Treatment Coordinator for
completion. The case manager can send the Medical Assessment form via mail, fax, or by way of
the client (at the client’s next scheduled visit). The Assessment must be updated at 6-month
intervals to ensure the provider and the case manager are coordinating client care. The data is to
be entered into FACTORS upon case manager receipt of the information. Clients who do not
have timely medical eligibility may be deemed ineligible for services.
The Medical Assessment must be completed by the client’s physician/clinical staff and should be
sent to the provider with signed release of information. It includes: � Demographic Information – To be completed by the case manager.
� Medical Assessment –To be completed by the client’s medical provider (MD, PA, NP, or
Cooperative Treatment Coordinator.) The assessment includes information regarding current lab
work, medical history, vaccination history and report of any current symptoms. Finally, the
provider should list any special needs they feel the client may require. Assessments must be signed
and dated by a qualified medical professional (MD, NP, PA, or a Cooperative Treatment
Coordinator.)
FORMS: Medical Assessment Form
Medical Assessment Letter to Provider
AIDS FOUNDATION OF CHICAGO MEDICAL INFORMATION/PRIMARY CARE FORM Medical Provider Eligibility Verification Form
DATE: _____ / ______ / ________ AGENCY: ___CASE MANAGER: ______________________ LAST NAME: ___________________________ FIRST: _____________________ MI: ________
DOB: ___ / ____ / ______ LAST FOUR DIGITS SS #: ____ ____ ____ ____
To be completed by Medical Provider/Clinical Staff
Provider Name/Address:
Provider Hospital/Clinic Affiliation:
Current HIV Status: � HIV Positive, not AIDS � HIV positive, AIDS Status Unknown � AIDS � Unknown (under 18
Last CD4 Count: _______________ Date of Last CD4 Count: _____________ mos. only)
Last Viral Load Count: _________________ Date of Last Viral Load Test: ___________________
Date of AIDS Diagnosis: ____________________ ____________
Please select all of the patient’s opportunistic infections within the last six months: �Candidiasis ( besides Oral Thrush) � Cryptococcal Disease � Cervical Cancer �Cytomegalovirus (CMV) �Pneumocystis Carinii Pneumonia (PCP)
�Lymphoma � Tuberculosis � Recurrent Genital Herpes �Kaposi Sarcoma
�Retinitis (CMV) � Histoplasmosis � Wasting �Toxoplasmosis �Mycobacterium Avium Complex (MAC)
�Mycobacterium Tuberculosis � Neuropathy �Syphilis � Human Papilloma Virus (HPV) �None � Unknown
Please select all the test/treatments the patient has received within the last six months:
�Pelvic Exam �Pap Smear �TB Skin Test (PPD Mantoux) � Treatment due to a positive TB skin test
�Screening or testing for Syphilis �Screening or testing for any treatable STI other than Syphilis or HIV
�Treatment for any STI other than Syphilis or HIV �Screening or testing for Hepatitis C � Treatment for Hepatitis C
�None �Unknown
�Other (Please explain): ___________________________________________
Is the patient currently taking any antiretroviral medications? Yes � No � No, Not needed at this time �
Is the patient currently taking any PCP prophylaxis? Yes � No � No, Not needed at this time �
Please select all of the patient’s HIV related symptoms/conditions within the last six months:
�Diarrhea �Skin Rashes �Thrush �Chronic Fatigue �Vomiting �Nausea �Persistent Fevers
�Weight Loss �Numbness/Pain in Hand and Feet �Persistent Headache �Swollen Lymph Nodes �None
Non-HIV Related Medical Conditions: ________________________________________________________________________________
Vaccinated against hepatitis A? (Complete Series) Yes � No � Not Applicable, Documented Immunity �
Vaccinated against hepatitis B? (Complete Series) Yes � No � Not Applicable, Documented Immunity �
Vaccinated against Pneumoccoccal Pneumonia? Yes � No � If yes, in what year __________
Primary Care Needs: �HIV/AIDS Specialists � Resource Identification/Referral �Information Services
�Other � None �Treatment Adherence
�Substance Abuse Services � Mental Health Services �Medication Adherence
Does the patient have a physical or mental HIV related impairment which would exclude them gaining or maintaining full-time employment? Yes � No �
Completing Provider/Clinical Staff Name:
Provider/Clinical Staff Signature:
Date:
411 South Wells Street, Suite 300 Tel (312) 922-2322 Chicago, IL 60607 Fax (312) 922-2916
MEMORANDUM
To: HIV Treatment Medical Provider
From: Cheryl Potts, Director of Care and Quality Improvement
AIDS Foundation of Chicago
Re: Medical Assessment Form
The AIDS Foundation of Chicago (AFC) is writing to request your collaboration with the
Northeastern Illinois HIV/AIDS Case Management Cooperative in collecting and reporting required
health-related information on your patients who are receiving case management services.
HIV case management has been identified by the Health Resources and Services Administration
(HRSA) as a “core service” that facilitates linkage to and maintenance of clinical care and includes
treatment coordination. In light of this, the Northeastern Illinois Case Management Cooperative will
have a focus to track client health indicators with the purpose of supporting adherence to clinical
treatment and medication. In order to ensure that these activities complement clinical care and do not
duplicate efforts on the part of clinical providers, AFC requests that medical providers work with
case managers to ensure consistent communication for the purposes of coordinating client treatment.
The attached Medical Assessment Form is a key tool in allowing AFC to collect HIV medical care
information on our shared clients, as required by HRSA. Medical providers will be contacted by the
case manager at bi-annual (six month) intervals for each client with the purpose of completing the
attached form. The assessment includes information regarding current lab work, medical history,
vaccination history and report of any current symptoms. In addition, the provider should list any
special needs they feel the client may require.
The purpose of this form is to collect and track the information listed in the previous paragraph. The
form will also be used to establish a client’s eligibility for AFC-funded programs including
Emergency Financial Assistance (EFA) and the Housing Assistance Program (HAP). To help
determine eligibility AFC must know if the client has an HIV-related physical or mental impairment
that would prevent them from maintaining full-time employment. This form is not intended to, nor
can it be used legally to help a client establish disability under Social Security guidelines.
Clinicians have reported it useful to keep a copy of this form on hand (in the client’s chart or
elsewhere) so that it can be completed at regularly scheduled visits. Case managers or clients may also
present this to you directly when needed to determine eligibility for programs. Timely and consistent
(at least every six months) completion of the forms is necessary to ensure adequate tracking of client
health indicators. Once completed, the form is to be sent via mail, fax, or physically carried by the
client to the case manager.
AFC and the case management cooperative thank you in advance for your partnership in improving
the health outcomes of people living with HIV. If you have any questions or concerns about this form,
you can feel free to call your associated case manager or me at 312.334.0958 or at
aidschicago.org | aidschicago.org/community | aidsrunwalk.org
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 6 – Service Planning
Date: March 21, 1996 (Previously SOP 3) Revised: February 29, 2008 Page 1 of 2
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the development and
revision of client-centered service plans.
POLICY: Client service plans will be developed and implemented in a timely manner upon client’s entry
into case management. Service plans will reflect a prioritized list of client needs as determined
through the assessment and acuity tools and will include core clinical and supportive service
needs. The service plan will be revised at a minimum of every six months.
PROCEDURE: An initial service plan will be developed for all clients enrolled in case management and will be
revised at a minimum of every six (6) months. Case managers will engage clients in the
formulation of a service plan that meets the needs identified during the assessment process by the
assessment and acuity tools. This will be an interactive process, and every effort will be made to
solicit client input and consensus. During this process, the case manager and client will:
• identify and rank problems needing resolution;
• identify resources available to the client;
• identify the roles the client and case manager will take in accessing services;
• determine the frequency and location of contacts (based also on acuity level); and
• identify other service providers involved in the client’s care.
This plan will be recorded in a standardized format developed by each agency that includes:
problem statement, intervention or action, role of client and case manager in addressing the
problem, time frame, and desired outcome. Case managers are strongly encouraged to write
specific goals and objectives in the SMART format: specific, measurable, attainable, realistic, and time-oriented. Changes in the implementation of the service plan must be documented in the
client’s chart via progress notes. Service plans must be signed by both the case manager and the
client.
Service plans must be revised whenever changes occur in the client needs. At this time the case
manager and client must meet and review the service plan to identify goals accomplished and
new client needs. Case managers are required to conduct a formal reassessment, including
updated service plan, at least every six(6) months. See SOP 8 for more information on
Reassessments.
FORMS: Sample Service Plan Format
SERVICE PLAN
Client Name: ______________________________________________
Service Plan Date; __________________________________________
Problem
Identification
Outcome Resources/
Referrals
Client Roles Case Manager
Roles
Target Date
Client Signature: ____________________________________ Case Manager Signature: _________________________________
Date: _____________________________________________ Date: _________________________________________________
Date of next Service Plan: ________________________
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 7 – Referral Agreements and Memoranda of Agreement
Date: February 29, 2008 Page 1 of 2
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the means of
establishing and utilizing referral agreements and memoranda of agreement with external
agencies for the purposes of case management services.
POLICY: Quality case management requires subcontracted agencies to build and maintain relationships
with other service providers, especially in cases where these relationships result in expansion of
the continuum of HIV services a client can access. These relationships exist on varying levels of
specificity and responsibility based on the desired outcomes. Agencies must have formalized
mechanisms to ensure access to services not provided at the assigned case managed agency
through referral agreements. In addition, memoranda of agreement ensure a formalized
relationship between two service providers that address the provision of services and
data/information sharing.
At all levels, priority must be given to establish collaborations with agencies providing core
clinical services and other levels of case management. Case managers must be aware of all
referral options available to them and make thoughtful referrals. In addition, subcontracted
agencies are required to follow up on referrals made and track the outcomes.
PROCEDURE:
Recognizing that the level and type of services offered at each subcontracted case management
agency vary, the Cooperative encourages established both formal and informal linkages with
outside community agencies and organizations to fulfill the charge of providing holistic case
management services to clients. There is an expectation that agencies will work to establish
formalized linkages in each of the main areas of service provision, specifically related to core
services under HRSA’s definition (medical case management, mental health, substance use, oral
health, and primary care). Other linkages with nutrition, food services, housing, and other non-
core services are also strongly encouraged. In addition, for ease of client transition between
various levels of case management services, subcontracted agencies are required to established
formal linkages with providers of other case management services not provided at the
subcontractor agency. Two types of linkage agreements exist and are described below:
Referral Agreements
Case management agencies are encouraged to establish referral agreements with other service
providers that can ensure access to services (core and non-core) not provided at the case
management agency. Referral agreements are relatively vague and open agreements that outline
a basic relationship between two agencies. Oftentimes, these agreements are limited to a brief
description of the services at each agency to which clients will be referred for services. There is
no expectation for data sharing or case conferencing regarding client care once the referral has
been made.
When a case manager makes a referral for a client to an outside agency utilizing one of the
agency’s established referral agreements or another connection, that referral must be documented
in the client’s chart and must include a signed release of information.
Memoranda of Agreement
Formalized linkages must be documented through an authorized and signed Memoranda of
Agreement (MOA) between the two organizations. MOAs must be updated annually. To the
extent possible, these agreements should include a specific procedure for referrals. Agreements
must address identified service priorities that are based on core clinical services, defined by
HRSA, and number of clients seen by agency. Agreements must address the following factors
that include but are not limited to:
• The services(s) to be provided, the number of participants to be served, the period in
which the services(s) will be provided, and, if known, the monetary value of the services;
• Priority areas addressed;
• Relationship between agencies and services provided overall between the two;
• Specific, identified contact staff for both agencies, including the extent of the authority
and responsibility both will take in the collaboration;
• Mechanisms for referral and referral tracking; and
• Mechanisms for treatment and service coordination (i.e. case conferencing) and
expectations of data sharing.
When a case manager makes a referral for a client to an outside agency utilizing one of the
agency’s established MOA agreements or another connection, that referral must be documented
in the client’s chart and must include a signed release of information.
FORMS:
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 8 - Reassessments
Date: March 21, 1996 (Previously SOP 5) Revised: February 29, 2008 Page 1 of 7
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding reassessment of current
client needs and progress towards goals set in the service plan.
POLICY: Case managers will reassess client needs and acuity scores no less than every six (6) months and
update the client service plan accordingly. In addition, case managers will update all necessary
eligibility documentation during this process.
PROCEDURE: Assessment is case management activity that is client-centered and ongoing throughout a client’s
enrollment in services. A formal client reassessment and service plan must be conducted at least
every six months and documented in the client’s chart. Reassessment includes a summary of
progress in the client’s situation, indicates changes in client need, and updates the client acuity
rating. By revisiting the service plan and acuity on a regular basis, case managers ensure that
progress is being made and the client needs are being met. Reassessment, like service planning,
can and must be a collaborative process between the case manager and client.
Below is a list of required assessments to be conducted at every six-month reassessment:
• Acuity scale (Parts 1 and 2) (SOP 5A)*
• Case Status Change/Reassessment Form *
• Medical Assessment Form (completed by physician) (SOP 5B)*
• Updated Service Plan (SOP 6)
* Must be entered into AFC’s client-level data system
In addition to conducting the required assessment, case managers must also update eligibility
documentation on an annual basis at the reassessment. Below is a list of required documentation
to be collected annually:
• Client Photo ID
• Proof of Residency
• Proof of Income
• AFC Consent to Release Information
This list is also available in the Ryan White Reassessment Checklist, which includes specific
information on each required item. In cases where clients do not have income or health
insurance, AFC will accept a letter signed by both the client and case manager affirming that the
client has no source of income or insurance as adequate documentation.
FORMS:
Case Status Change/Reassessment Form
Ryan White Reassessment Checklist
Ryan White Reassessment Checklist
Forms/Documentation Date Completed/Received The following are needed every six months: Acuity Scale (AFC forms Parts 1 and 2) ____________ Case Status Change/Reassessment Form (pages 1-4) (AFC form) ____________ Medical Assessment to Physician (AFC form) Date Sent: ____________
Date Received: ____________ The following are needed annually: Client Photo ID (Drivers License/State ID) ____________ (Only if the photo ID currently in the file has expired since the client’s last reassessment)
Client Proof of Residency ____________
� Utility bill with client name and current address
� Driver’s license or state ID with current address
� Documents issued by the state or federal government (i.e. a motor vehicle registration form, a current Illinois voter registration card, or a current Medicaid card)
� Current rental or lease agreement with client name
Client Proof of Income ____________
� Current pay stubs – 1 month’s worth
� Most recent W2 forms
� Unemployment Benefits Statements
� Most recent SSI benefits statement
� For clients with no income, a verification letter must be completed, signed and dated by client and cm
AFC Consent to Release Information (AFC form) ____________
AIDS FOUNDATION OF CHICAGO
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE STATUS CHANGE/ REASSESSMENT FORM
REASSESS DATE: ____ ____ / ____ ____ / ____ ____ CLIENT ID #: ________________________ AGENCY: _____________________________________CASE MANAGER: ___________________________________________________
LAST NAME: _____________________________________________ FIRST: ________________________________________________ MI:
________
DOB: ____ / ____ / _________ SS#: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
--CHECK ONLY ONE IN EACH OF THE FOLLOWING CATEGORIES (check NO CHANGE if information is the SAME as INTAKE)--
MARITAL STATUS:
����NO CHANGE
DIVORCED _____
MARRIED _____
SEPARATED _____
WIDOWED _____
ENGAGED _____
PARTNERED _____
SINGLE _____
UNKNOWN _____
HIGHEST EDUCATION LEVEL COMPLETED:
� � � � NO CHANGE
GRADE SCHOOL _____
SOME HIGH SCHOOL _____
HIGH SCHOOL GRADUATE _____
SOME COLLEGE _____
ASSOCIATE’S DEGREE _____
UNDERGRADUATE DEGREE _____
GRADUATE DEGREE _____
VOCATIONAL DEGREE _____
TOTAL NUMBER IN HOUSEHOLD: ______
� � � � NO CHANGE
TOTAL NUMBER OF DEPENDANTS: _______
� � � � NO CHANGE
PRIMARY CARE SOURCE:
� � � � NO CHANGE
PRIVATE PRACTICE _____
HMO _____ COMMUNITY HEALTH CTR.
_____ HOSPITAL CLINIC _____
OTHER CLINIC _____ EMERGENCY ROOM _____
OTHER _____ NONE _____
SEROSTATUS: *
� � � � NO CHANGE
AIDS DIAGNOSIS ___ HIV+/ NOT AIDS ___
HIV+/AIDS UNKNOWN ___ UNKNOWN ___
CASE STATUS CHANGE INFORMATION:
� � � � NO CHANGE
TRANSFER INFORMATION:
EFFECTIVE DATE ____/____/______ NEW PROGRAM: �DRS �CORRECTIONS �CHHP �SHP �PACPI
NEW CASE MANAGER _____________________ AGENCY _______________________________
DISCHARGE INFORMATION: EFFECTIVE DATE OF DISCHARGE: ____/____/________
REASON FOR DISCHARGE: � Administrative discharge � Assisted living/nursing home placement � Death
� DCFS placement � Incarceration � Ineligible � Moved out of EMA �No services needed � Refused services � Whereabouts unknown
DEMOGRAPHICS/CONTACT INFORMATION � � � � NO CHANGE
ADDRESS: ________________________________________ CITY: _________________________ COUNTY: __________________ ZIP: ___________
PHONE: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___ OTHER PHONE/CELL: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
#1 EMERGENCY CONTACT: _____________________________ RELATIONSHIP: ___________________ PHONE:( __ __ __ ) __ __ __ - __ __ __ __
IS THE #1 EMERGENCY CONTACT AWARE THAT THE CLIENT IS HIV+? YES ���� NO ���� #2 EMERGENCY CONTACT: _____________________________ RELATIONSHIP: ____________________ PHONE:( __ __ __ ) __ __ __ - __ __ __ __
IS THE #2 EMERGENCY CONTACT AWARE THAT THE CLIENT IS HIV+? YES ���� NO ����
INFORMAL SUPPORTS (HOUSEHOLD MEMBERS) � � � � NO CHANGE
NAME RELATIONSHIP GENDER DOB/AGE RACE ETHNICITY
*At reassessment, acceptable documentation of serostatus, photo ID, and proof of residency must be provided by the client and recorded in the client
case management record. Page 1
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE REASSESSMENT FORM Page 2
LIVING ARRANGEMENT CURRENT TYPE: � � � � NO CHANGE
INSTITUTION HOUSING PROGRAMS COMMUNITY � � � � HOSPITAL
� � � � INSTITUTION
� � � � JAIL, CORRECTIONAL FACILITY
� � � � PSYCHIATRIC HOSPITAL
CURRENT HOUSING START DATE: ___/___/_____
� � � � GROUP OR FOSTER HOME
� � � � SHELTER
� � � � SUPPORTIVE HOUSING UNIT
� � � � SUBSTANCE ABUSE FACILITY
� � � � TRANSITIONAL HOUSING
� � � � HOMEOWNERSHIP
� � � � HOTEL/MOTEL
� RENTAL UNIT
� SRO
� � � � STREET
� � � � OTHER
� � � � UNKNOWN/UNREPORTED
INSURANCE SOURCES: � � � � NO CHANGE
Insurance Types: AIDS Drug Assistance Program, IL All Kids, CHIC, GA (General Assistance), Medicaid, Medicare, None, Other, Private Insurance, Other Public Insurance, VA Benefits
Insurance Type Medications Covered? Y/N Primary? Y/N Start Date End Date
_______________ _________________________ ________ ___/___/_____ ___/___/_____
_______________ _________________________ ________ ___/___/_____ ___/___/_____
_______________ _________________________ ________ ___/___/_____ ___/___/_____
_______________ _________________________ ________ ___/___/_____ ___/___/_____
INCOME SOURCES: (Update at every reassessment) How much money did you receive from the following sources in the past 30 days?
Amount Start Date End Date Employment/wages/salary (net income) $ __________ __/__/____ __/__/____ Unemployment/workers compensation $ __________ __/__/____ __/__/____ Public assistance/AFDC/welfare $ __________ __/__/____ __/__/____ Child support/alimony $ __________ __/__/____ __/__/____ Pension/benefits/Social Security $ __________ __/__/____ __/__/____ Partner, family or friends $ __________ __/__/____ __/__/____ (money for personal expenses) $ __________ __/__/____ __/__/ ____ Other Income: _________ $ __________ __/__/____ __/__/____
LEGAL HISTORY (Check all that apply to the last six months, ONLY): � � � � NO CHANGE � Felony conviction(s) � Misdemeanor conviction(s) � Been in jail Date of most recent release ____/____/______ � Been in prison Date of most recent release ____/____/______ � Currently under: (circle one) probation parole supervision � Required to register as sex offender (circle one) adults children � Court date(s)______________________ � Arrest(s) � Other____________________________
HEALTH CARE INFORMATION: (Update at every reassessment)
Primary Care Provider (if different than previously noted): Name: _______________________________ Phone: _______________
Type of Physician (I.e., Infectious Disease, General Practitioner, Nurse Practitioner): __________________________
Address:
Hospital/Clinic Affiliation:
Date of last HIV related medical appointment? __/__/____ Applied for ADAP: � Yes � No Date Applied: ____________________ Currently Receiving ADAP Drugs: Yes � No � Applied for CHIC: � Yes � No Date applied: ____________________ Currently Receiving CHIC: Yes � No � Applied for Medicaid: � Yes �No Date Applied: ____________________Currently Receiving Medicaid: Yes � No � If not on one of the above programs; how are you receiving your medications? Have you been prescribed medications for your HIV? �Yes (continue) �No How often do you feel that you have difficulty taking your HIV medications on time? By “on time” we mean no more than two hours before or after the time your doctor told you to take it. � Never � Rarely � Most of the time � All of the time On average, how many days PER WEEK would you say that you missed at least one dose of you HIV medications? � Never � 1-3 days per week � 4-6 days per week � Every day When was the last time you missed at least one dose of your HIV medications?
� Never � More than two weeks ago � 1-2 weeks ago � Within the past week
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE
CASE REASSESSMENT FORM Page 3 HEALTH CARE INFORMATION (continued):
Date you last took HIV medications: Date of last CD4 count? __/__/____
Are you currently pregnant? � Yes � No
Please select all the medical conditions that a doctor, nurse, or other medical provider has told you that you have:
� None � Endocarditis/Infection of Heart Valve � Hepatitis C � Other permanent numbness
� Arthritis � Epilepsy � Hypertension � Paralysis
� Asthma/Emphysema � Glaucoma � Liver Disease � Tuberculosis
� Diabetes � Heart Disease � Obesity � Stroke � Cancer (Please specify type): � Other ________________________________
MENTAL HEALTH: (Update at every reassessment)
In the last six months, have you received treatment for any psychological condition? Yes � No � If yes, what was
the treatment for: � Schizophrenia � Depression � Bipolar Disorder � Anxiety Disorder � Personality Disorder
� Others: ________________________________________________________ � Was treated, but does not know diagnosis, but their symptoms are: ____________________________________________ Have you been hospitalized for a psychiatric condition in the last six months? Yes � No �
Name of hospital: ___________________ Dates of hospitalization: _______-______
What were the circumstances? Current Medications: _________________________________________________________________________________________________
Have you been able to follow through with taking the prescriptions? Yes ���� No ���� Please explain:
Have you been able to follow through with doctors and counseling appointments? Yes ���� No ���� Please explain:
In the past six (6) months, have you considered harming yourself or others? Yes ���� No ���� If yes, please explain:
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE
CASE REASSESSMENT FORM Page 4 Eligibility Checklist for Client Services: Food Assistance
� � � � Client’s income is at or below 50% of the area median income to be eligible. Documentation of income to be kept in chart, and documented above in Income Sources. � � � � Client affirms that they do not receive assistance from Public Aid (Link Card) � � � � Client affirms that they are not receiving food from Vital Bridges � � � � Client affirms that they are not able to access local food pantries Clients must meet ALL of the above eligibility criteria to receive emergency food voucher assistance.
Client is eligible for emergency food assistance: YES ���� NO ���� CTA/Metra/PACE Transportation:
� � � � Client’s income is at or below 50% of the area median income to be eligible. � � � � Client affirms that he/she has no family or friends that can transport him/her to appointments � � � � Client affirms that there are no clinic/hospital van services available � � � � Client affirms that he/she does not have an RTA reduced fare card and is not eligible � � � � Client affirms that he/she does not have an active medical card
Clients must meet ALL of the above eligibility criteria to receive CTA/Metra/PACE transportation assistance.
Client is eligible for public transportation assistance: YES ���� NO ���� Taxi Services:
� � � � *Client’s income is at or below 50% of the area median income to be eligible. � � � � *Client affirms that he/she has no other transportation resources available to them. � � � � *Client affirms that he/she does not have an active medical card. � � � � *Client affirms that he/she does not have an RTA reduced fare card and is not eligible. � � � � Client has demonstrated difficulty ambulating (i.e. cannot climb stairs, cannot walk more than 20 feet) � � � � Client has a documented physical disability that impedes safe access to public transportation. � � � � Client affirms that public transportation does not serve point of origin or destination. � � � � Client affirms that he/she is traveling with two or more infants or toddlers.
*Client must meet ALL of the first four eligibility criteria and at least one of the remaining four eligibility criteria in order to be eligible to receive taxi transportation assistance.
Client is eligible for taxi services: YES ���� NO ����
I have participated in the completion of this document for planning of my care. I certify that all information provided is accurate and truthful to the best of my knowledge. I understand that I may deemed ineligible for services based on some of the responses to these questions. ______________________________________ _____/____/_________ Client or Legal Guardian signature Date
______________________________________ _____/____/_________ Case Manager Date
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 9 - Documentation
Date: March 21, 1996 Revised: February 29, 2008 Page 1 of 4
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding records and paperwork
needed to properly document continuity of care for clients.
POLICY: Agencies will maintain client charts with all required paperwork and documentation of client
eligibility and service utilization in a way that is professional, organized, and confidential.
PROCEDURE: Client records will be maintained by each Cooperative subcontracted case management agency.
Cooperative record keeping requirements are not meant to supplant or supersede existing agency
requirements but to determine a minimum standard across Cooperative subcontractors. AFC
recognizes that a growing number of agencies have access to and utilize various electronic
medical records and/or other client-level data systems, which may collect some of the
information required for documentation. In such cases, hard copy files must also be maintained
with client information including but not limited to those elements outlined in the Case
Management Record Review utilized during AFC site visits as well as all elements outlined in
the Ryan White Initial Assessment Checklist and Ryan White Reassessment Checklists. (See
also SOP 3 and SOP 8 for details on Intake and Reassessment documentation requirements. See
also SOP 17 for details of the Site Visit process for chart auditing.)
Case managers must keep copies of any and all entitlements and benefits applications completed
on behalf of the client. All documentation must be legible, kept in an organized manner, and
available for administrative review as needed. Client charts must be kept for five (5) years on all
closed or inactive clients.
All client documentation, both electronic and hard copy, must be kept in a confidential, secure,
and locked space with access limited only to the case manager, the case manager supervisor, and
any other agency program staff.
FORMS:
Case Management Record Review
Ryan White Initial Assessment Checklist
Ryan White Reassessment Checklist
CASE MANAGEMENT RECORD REVIEW Use the following codes in documenting components in the case management service record:
“1” for present “0” for absent “NA” for not applicable “N” for note
CRITERIA 1 2 3 4 5
Record ID# Documentation of HIV Status
Acuity score included
# Contacts (last 3 months)
Contact are consistent with acuity score
Intake date reasonable from screening date
SERVICE RECORD INCLUDES Completed intake/assessment forms-
● Page 1
● Page 2
________
________
________
________
________
Consent to enroll-signed & witnessed
Release of information-signed & witnessed
Rights and responsibilities- signed &
witnessed
Service plan is in file
Service plan is up to date
Linkage to Primary Care is documented
Monitoring and intervention activities are
included in progress notes(acuity, referrals,
notes)
Linkages made are documented
ECA is included in chart with all required
documentation.
Documentation in charts of other options
used before ECA.
Progress notes reflect the payment made for
client with ECA.
Progress notes are dated
Progress notes are signed
Change of status form (date)
Reassessment every six months
(documentation otherwise)
Supervisory notes in client record
Discharge plan
COMMENTS:
TOTAL SCORE
Ryan White Initial Assessment Checklist (To be completed at intake for all Ryan White clients)
Forms/Documentation Date Completed/Received
Client Screening Form (received from AFC) ____________
Acuity Scale (AFC forms Parts 1 and 2) ____________
Consent to Enroll in Central Database (AFC form) ____________
Consent to Participate in Case Management (AFC form) ____________
AFC Consent to Release Information (AFC form) ____________
Case Intake Form (pages 1-4) (AFC form) ____________
Medical Assessment to Physician (AFC form) Date Sent: ____________
Date Received: ____________
Client Photo ID (Drivers License/State ID) ____________
Client Proof of Residency ____________
� Utility bill with client name and current address
� Driver’s license or state ID with current address
� Documents issued by the state or federal government (i.e. a motor vehicle registration form, a current Illinois voter registration card, or a current Medicaid card)
� Current rental or lease agreement with client name
Client Proof of Income ____________
� Current pay stubs – 1 month’s worth
� Most recent W2 forms
� Unemployment Benefits Statements
� Most recent SSI benefits statement
� For clients with no income, a verification letter must be completed, signed and dated by client and cm
Client Proof of HIV Status ____________
Client’s name must be on any of the following:
� Medical Assessment with diagnosis identified
� Official lab result with any detectable viral load
� Positive ELISA & Western Blot
� Positive Serology assay
� Positive DNA PCR assay
Client Rights and Responsibilities (Agency Form) ____________
Client Grievance Policy (Agency Form) ____________
HIPAA Policy (when applicable) (Agency Form) ____________
Ryan White Reassessment Checklist
Forms/Documentation Date Completed/Received The following are needed every six months: Acuity Scale (AFC forms Parts 1 and 2) ____________ Case Status Change/Reassessment Form (pages 1-4) (AFC form) ____________ Medical Assessment to Physician (AFC form) Date Sent: ____________
Date Received: ____________ The following are needed annually: Client Photo ID (Drivers License/State ID) ____________ (Only if the photo ID currently in the file has expired since the client’s last reassessment)
Client Proof of Residency ____________
� Utility bill with client name and current address
� Driver’s license or state ID with current address
� Documents issued by the state or federal government (i.e. a motor vehicle registration form, a current Illinois voter registration card, or a current Medicaid card)
� Current rental or lease agreement with client name
Client Proof of Income ____________
� Current pay stubs – 1 month’s worth
� Most recent W2 forms
� Unemployment Benefits Statements
� Most recent SSI benefits statement
� For clients with no income, a verification letter must be completed, signed and dated by client and cm
AFC Consent to Release Information (AFC form) ____________
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 10 – Direct Data Entry
Date: February 29, 2008 Page 1 of 1
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding electronic records and
data reporting needed to properly document continuity of care for clients.
POLICY: Currently being developed to reflect Client Track needs.
PROCEDURE: Currently being developed to reflect Client Track needs.
FORMS:
CASE MANAGEMENT POLICY
Case Management Process
Subject: SOP 11 - Client Discharge/Case Closure
Date: December 2007 Revised: February 29, 2008 Page 1 of 9
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding reasons and consistent
procedure for the closure and/or transfer of case managed clients.
POLICY: Case-managed clients can be transferred to another agency, closed for case management services
at a given agency, or terminated completely from the Cooperative under the circumstances
outlined below, with the support of the case management supervisor and AFC program staff.
These situations are meant to provide guidelines regarding client closure and discharge and are
not meant to represent all possible case scenarios.
PROCEDURE:
Transfer of Clients
A client requesting or requiring to be transferred from one case management agency to another
within the Cooperative must do so via his or her currently assigned case manager. Acceptable
reasons for transfer are limited to the following:
The current case manager must get approval from their case management supervisor to make the
transfer; documentation of this approval must be kept in the client chart. Once approval is
established, the current case manager must contact the new case manager, who must then agree
to accept the client. The case manager must prioritize transfer within the current case
management agency. If this is not possible or appropriate, the current case manager will arrange
for the transfer to a new agency. Acceptable reasons for transfer include:
• Administrative discharge
• Assisted living/nursing home placement
• Death
• DCFS placement
• Incarceration
• Client becomes ineligible for services
• Moved out of EMA
• No services needed
• Refused services
• Whereabouts unknown
Once the new case manager has been identified, the currently assigned case manager will then
complete a Change of Status form. The form remains a part of the case management chart. The
client’s status must then be updated in AFC’s client-level data system by opening the client to
the new case manager. NOTE: The case manager who is transferring the client must update all
client demographics and case information in the client-level data system before the client is
assigned to the new case manager.
To facilitate ease of transition and continuity of care for a transferring client, the previously
assigned case manager must document in the client’s chart via the last case note any and all
information the future case manager may need for service continuity; this should include, but is
not limited to, any entitlements or benefits the client is receiving (ADAP, HAP, EFA, etc.), a list
of needed releases of information, and an overview of the current issues being addressed on the
client’s service plan. Upon the client’s approval and with a signed release of information, the
transferring case manager must release the client’s entire chart to the new case manager.
Contact AFC before transferring a client to any intensive case management program.
Closure of Clients
There are two distinct types of case closure: situational closure and administrative discharge.
Situational Closure Clients may be closed by a case management agency when:
• The client’s whereabouts are unknown and no contact has been made with the client in
more than six months. Before the case is closed, the case manager must document
attempted contacts to the client and must send a certified letter of notification to the
client’s last known address.
• The client moves out of the EMA.
• The client is deceased.
• The client is incarcerated for more than six months.
• The client no longer wants/has a need for case management services.
In cases of situational closure, the assigned case manager must discuss closure with the case
management supervisor. If the supervisor agrees to the closure, a Change of Status form must be
completed by the case manager. The form remains a part of the case management chart. The
client’s status must also then be updated to “closed” status in AFC’s client-level data system.
Administrative Discharge While case managers and clients are always encouraged to work through conflicts internally,
utilizing the grievance procedure as needed (see SOP 12), AFC recognizes there are instances
when it becomes necessary to discharge a client from a case management agency. Case managers and agencies are not permitted to indiscriminately discharge a client without reasonable cause. However, in accordance with the procedure outlined below, a client’s case
may result in administrative discharge if a behavior or situation cannot be resolved.
A client’s case can result in administrative discharge from the assigned case management agency
if the agency can document one or more of the following circumstances:
• Belligerent language or attitude toward case manager or other agency staff;
• Threat or use of violence;
• Illegal substance use on the agency premises;
• Proven theft of agency or other client property;
• Actions violating the confidentiality of other clients at the agency;
• Willful refusal to follow through with agreed upon service plan;
• Proven dishonesty and/or falsification of documents;
• Violation of any other aspect of the agency’s policies and/or Rights and Responsibilities;
and/or
• Other behavioral issues discussed with AFC.
Administrative discharge is left to the discretion of the assigned case management agency.
With appropriate substantial documentation, a client does not have to agree to administrative
discharge. If a case manager and case management supervisor are in agreement for the
administrative discharge of a client, the supervisor should contact AFC to inform Program Staff
of the discharge. A letter must then be generated on agency letterhead and mailed or otherwise
given to the client. The letter must include the grievance procedure, the phone number for AFC,
and the client’s right to request case management services from another agency. The client must
be informed in this letter that in order to re-engage in services at a new case management agency,
the new agency will require a behavioral contract. A copy of this letter must be kept in the case
management chart. A copy of this letter must also be submitted to AFC.
Should a discharged client request case management at another Cooperative agency, AFC will
assist the new case management agency in generating a behavioral contract. This contract will
detail expectations for the client related to the reason for his or her discharge from the previous
case management agency. The new case manager and the client must agree to and sign the
contract. The client will be informed that violation of the behavioral contract will result in a
lifetime termination from case management services Cooperative-wide.
It should be noted that administrative discharge according to this policy applies only to a client’s
case management services. Administrative discharge will not necessarily affect a client’s status
in primary care, mental health, or other non-AFC funded services. However, clients must be
informed that due to the nature of the screening and eligibility requirements of HAP, EFA, and
transportation, termination from case management services will impede access to these
programs.
Termination of Clients from the Cooperative
In a few very rare but serious circumstances, clients may be automatically and permanently
terminated from case management services Cooperative-wide. Those circumstances include:
• Threatening a case manager, other agency staff, AFC staff, or another client with a
weapon or physical force (documented with a Police Report);
• Two consecutive violations of an established behavioral contract; and/or
• Actions violating the confidentiality of other agency clients.
In cases of termination, the case manager must contact AFC immediately. AFC will make the
final determination for termination. The circumstances must be documented thoroughly in the
case management chart, signed off on by the case manager, the case management supervisor, and
a member of the AFC program staff. A Change of Status form must be completed and the
client’s status should be changed to “closed” in AFC’s client-level data system. A list of
terminated clients will be maintained at AFC.
FORMS: Change of Status Form
Behavioral Contract Template
AIDS FOUNDATION OF CHICAGO
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE STATUS CHANGE/ REASSESSMENT FORM
REASSESS DATE: ____ ____ / ____ ____ / ____ ____ CLIENT ID #: ________________________ AGENCY: _____________________________________CASE MANAGER: ___________________________________________________
LAST NAME: _____________________________________________ FIRST: _____________________________________________ MI: ________
DOB: ____ / ____ / _________ SS#: ___ ___ ___ - ___ ___ - ___ ___ ___ ___
--CHECK ONLY ONE IN EACH OF THE FOLLOWING CATEGORIES (check NO CHANGE if information is the SAME as INTAKE)--
MARITAL STATUS:
����NO CHANGE
DIVORCED _____
MARRIED _____
SEPARATED _____
WIDOWED _____
ENGAGED _____
PARTNERED _____
SINGLE _____
UNKNOWN _____
HIGHEST EDUCATION LEVEL COMPLETED:
� � � � NO CHANGE
GRADE SCHOOL _____
SOME HIGH SCHOOL _____
HIGH SCHOOL GRADUATE _____
SOME COLLEGE _____
ASSOCIATE’S DEGREE _____
UNDERGRADUATE DEGREE _____
GRADUATE DEGREE _____
VOCATIONAL DEGREE _____
TOTAL NUMBER IN HOUSEHOLD: ______
� � � � NO CHANGE
TOTAL NUMBER OF DEPENDANTS: _______
� � � � NO CHANGE
PRIMARY CARE SOURCE:
� � � � NO CHANGE
PRIVATE PRACTICE _____
HMO _____ COMMUNITY HEALTH CTR.
_____ HOSPITAL CLINIC _____
OTHER CLINIC _____ EMERGENCY ROOM _____
OTHER _____ NONE _____
SEROSTATUS: *
� � � � NO CHANGE
AIDS DIAGNOSIS ___ HIV+/ NOT AIDS ___
HIV+/AIDS UNKNOWN ___ UNKNOWN ___
CASE STATUS CHANGE INFORMATION:
� � � � NO CHANGE
TRANSFER INFORMATION:
EFFECTIVE DATE ____/____/______ NEW PROGRAM: �DRS �CORRECTIONS �CHHP �SHP �PACPI
NEW CASE MANAGER _____________________ AGENCY _______________________________
DISCHARGE INFORMATION: EFFECTIVE DATE OF DISCHARGE: ____/____/________
REASON FOR DISCHARGE: � Administrative discharge � Assisted living/nursing home placement � Death
� DCFS placement � Incarceration � Ineligible � Moved out of EMA �No services needed � Refused services � Whereabouts unknown
DEMOGRAPHICS/CONTACT INFORMATION � � � � NO CHANGE
ADDRESS: ________________________________________ CITY: _________________________ COUNTY: __________________ ZIP: ___________
PHONE: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___ OTHER PHONE/CELL: ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
#1 EMERGENCY CONTACT: _____________________________ RELATIONSHIP: ___________________ PHONE:( __ __ __ ) __ __ __ - __ __ __ __
IS THE #1 EMERGENCY CONTACT AWARE THAT THE CLIENT IS HIV+? YES ���� NO ���� #2 EMERGENCY CONTACT: _____________________________ RELATIONSHIP: ____________________ PHONE:( __ __ __ ) __ __ __ - __ __ __ __
IS THE #2 EMERGENCY CONTACT AWARE THAT THE CLIENT IS HIV+? YES ���� NO ����
INFORMAL SUPPORTS (HOUSEHOLD MEMBERS) � � � � NO CHANGE
NAME RELATIONSHIP GENDER DOB/AGE RACE ETHNICITY
*At reassessment, acceptable documentation of serostatus, photo ID, and proof of residency must be provided by the client and recorded in the client case management record.
Page 1
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE REASSESSMENT FORM Page 2
LIVING ARRANGEMENT CURRENT TYPE: � � � � NO CHANGE
INSTITUTION HOUSING PROGRAMS COMMUNITY � � � � HOSPITAL
� � � � INSTITUTION
� � � � JAIL, CORRECTIONAL FACILITY
� � � � PSYCHIATRIC HOSPITAL
CURRENT HOUSING START DATE: ___/___/_____
� � � � GROUP OR FOSTER HOME
� � � � SHELTER
� � � � SUPPORTIVE HOUSING UNIT
� � � � SUBSTANCE ABUSE FACILITY
� � � � TRANSITIONAL HOUSING
� � � � HOMEOWNERSHIP
� � � � HOTEL/MOTEL
� RENTAL UNIT
� SRO
� � � � STREET
� � � � OTHER
� � � � UNKNOWN/UNREPORTED
INSURANCE SOURCES: � � � � NO CHANGE
Insurance Types: AIDS Drug Assistance Program, IL All Kids, CHIC, GA (General Assistance), Medicaid, Medicare, None, Other, Private Insurance, Other Public Insurance, VA Benefits
Insurance Type Medications Covered? Y/N Primary? Y/N Start Date End Date
_______________ _________________________ ________ ___/___/_____ ___/___/_____
_______________ _________________________ ________ ___/___/_____ ___/___/_____
_______________ _________________________ ________ ___/___/_____ ___/___/_____
_______________ _________________________ ________ ___/___/_____ ___/___/_____
LEGAL HISTORY (Check all that apply to the last six months, ONLY): � � � � NO CHANGE � Felony conviction(s) � Misdemeanor conviction(s) � Been in jail Date of most recent release ____/____/______ � Been in prison Date of most recent release ____/____/______ � Currently under: (circle one) probation parole supervision � Required to register as sex offender (circle one) adults children � Court date(s)______________________ � Arrest(s) � Other____________________________
INCOME SOURCES: (Update at every reassessment) How much money did you receive from the following sources in the past 30 days?
Amount Start Date End Date Employment/wages/salary (net income) $ __________ __/__/____ __/__/____ Unemployment/workers compensation $ __________ __/__/____ __/__/____ Public assistance/AFDC/welfare $ __________ __/__/____ __/__/____ Child support/alimony $ __________ __/__/____ __/__/____ Pension/benefits/Social Security $ __________ __/__/____ __/__/____ Partner, family or friends $ __________ __/__/____ __/__/____ (money for personal expenses) $ __________ __/__/____ __/__/ ____ Other Income: _________ $ __________ __/__/____ __/__/____
HEALTH CARE INFORMATION: (Update at every reassessment)
Primary Care Provider (if different than previously noted): Name: _______________________________ Phone: _______________
Type of Physician (I.e., Infectious Disease, General Practitioner, Nurse Practitioner): __________________________
Address:
Hospital/Clinic Affiliation:
Date of last HIV related medical appointment? __/__/____
Applied for ADAP: � Yes � No Date Applied: ____________________ Currently Receiving ADAP Drugs: Yes � No �
Applied for CHIC: � Yes � No Date applied: ____________________ Currently Receiving CHIC: Yes � No �
Applied for Medicaid: � Yes �No Date Applied: ____________________Currently Receiving Medicaid: Yes � No �
If not on one of the above programs; how are you receiving your medications? Have you been prescribed medications for your HIV? �Yes (continue) �No How often do you feel that you have difficulty taking your HIV medications on time? By “on time” we mean no more than two hours before or after the time your doctor told you to take it. � Never � Rarely � Most of the time � All of the time On average, how many days PER WEEK would you say that you missed at least one dose of you HIV medications? � Never � 1-3 days per week � 4-6 days per week � Every day
When was the last time you missed at least one dose of your HIV medications?
� Never � More than two months ago � 1- days weeks ago � Within the past week
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE CASE REASSESSMENT FORM Page 3
HEALTH CARE INFORMATION: (Update at every reassessment)
Date you last took HIV medications: Date of last CD4 count? __/__/____
Please select all the medical conditions that a doctor, nurse, or other medical provider has told you that you have:
���� Rheumatism or Arthritis ���� Paralysis ���� Other permanent numbness
���� Multiple Sclerosis ���� Cerebral Palsy ���� Epilepsy
���� Parkinson’s Disease ���� Glaucoma ���� Diabetes
���� Liver Disease ���� Infection of the heart valve ���� Other ____________ ���� Cancer (Please specify type):
MENTAL HEALTH: (Update at every reassessment)
In the last six months, have you received treatment for any psychological condition? Yes � No � If yes, what was
the treatment for: � Schizophrenia � Depression � Bipolar Disorder � Anxiety Disorder � Personality Disorder
� Others: ________________________________________________________ � Don't Know Have you been hospitalized for a psychiatric condition in the last six months? Yes � No �
Name of hospital: ___________________ Dates of hospitalization: _______-______
What were the circumstances? Current Medications: _________________________________________________________________________________________________
Have you been able to follow through with taking the prescriptions? Yes ���� No ���� Please explain:
Have you been able to follow through with doctors and counseling appointments? Yes ���� No ���� Please explain:
In the past six (6) months, have you considered harming yourself or others? Yes ���� No ���� If yes, please explain:
SUBSTANCE USE (Update at every reassessment)
How many times in your life have you been treated for . . . ? (if none, code 0; if refused, code 77; if don’t know, code 88) Alcohol abuse l___l___l Drug abuse l___l___l
Type(s) of Drugs Used Days Used in Past 30 Days Years Used
□ Alcohol – any use at all ______________ _______ □ Alcohol to Intoxication ______________ _______ □ Heroin ______________ _______ □ Methadone ______________ _______ □ Other Opiates/Analgesics ______________ _______ □ Cocaine or Crack ______________ _______ □ Amphetamines/Speed ______________ _______ □ Marijuana/Hash ______________ _______ □ Hallucinogens /LSD/Mushrooms ______________ _______ □ Inhalants/Poppers ______________ _______ □ More than 1 substance in 1 day (incl. alcohol) ______________ _______
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE
CASE REASSESSMENT FORM Page 4 Eligibility Checklist for Client Services: Food Assistance
���� Client’s income is at or below 50% of the area median income to be eligible. Documentation of income to be kept in chart, and documented above in Income Sources. � � � � Client affirms that they do not receive assistance from Public Aid (Link Card) � � � � Client affirms that they are not receiving food from Vital Bridges � � � � Client affirms that they are not able to access local food pantries Clients must meet ALL of the above eligibility criteria to receive emergency food voucher assistance.
Client is eligible for emergency food assistance: YES ���� NO ���� CTA/Metra/PACE Transportation:
� � � � Client’s income is at or below 50% of the area median income to be eligible. � � � � Client affirms that he/she has no family or friends that can transport him/her to appointments � � � � Client affirms that there are no clinic/hospital van services available � � � � Client affirms that he/she does not have an RTA reduced fare card and is not eligible � � � � Client affirms that he/she does not have an active medical card
Clients must meet ALL of the above eligibility criteria to receive CTA/Metra/PACE transportation assistance.
Client is eligible for public transportation assistance: YES ���� NO ���� Taxi Services:
� � � � *Client’s income is at or below 50% of the area median income to be eligible. � � � � *Client affirms that he/she has no other transportation resources available to them. � � � � *Client affirms that he/she does not have an active medical card. � � � � *Client affirms that he/she does not have an RTA reduced fare card and is not eligible. � � � � Client has demonstrated difficulty ambulating (i.e. cannot climb stairs, cannot walk more than 20 feet) � � � � Client has a documented physical disability that impedes safe access to public transportation. � � � � Client affirms that public transportation does not serve point of origin or destination. � � � � Client affirms that he/she is traveling with more than two infants or toddlers.
*Client must meet ALL of the first four eligibility criteria and at least one of the remaining four eligibility criteria in order to be eligible to receive taxi transportation assistance.
Client is eligible for taxi services: YES ���� NO ����
I have participated in the completion of this document for planning of my care. I certify that all information provided is accurate and truthful to the best of my knowledge. I understand that I may deemed ineligible for services based on some of the responses to these questions. ______________________________________ _____/____/_________ Client or Legal Guardian signature Date
______________________________________ _____/____/_________ Case Manager Date
Northeastern Illinois Case Management Behavioral Contract SAMPLE
In order for me, CLIENT, to re-enter case management services through the Northeastern Illinois Case Management
Cooperative coordinated by the AIDS Foundation of Chicago (AFC) and to help ensure that services are able to
address my specific needs, I agree to adhere to the following:
I will continue to participate in case management services offered by AFC unless I choose, at any time, to refuse
such services or if I am discharged from participation in services for one or more of the following reasons:
• Non-compliance with required Division of Rehabilitative Services (DRS) Home Services Program (HSP)
contacts with my case manager (DRS HSP clients are required to have at least one face-to-face contact each
month with their case manager);
• Making verbal or physical threats to my case manager, HSP service provider, case management agency staff
or AFC staff ;
• Speaking in a vulgar or derogatory manner toward my case manager, HSP service provider, case
management agency staff or AFC staff. This includes the use of any written or verbal profanity;
• Falsifying any information that is requested by my case manager or AFC that is necessary for the provision
of case management services (including financial information); or
• Making any unsubstantiated allegations (including threats or thefts) against my case manager, HSP service
provider, case management agency staff or AFC staff. (Substantiated charges, which can be verified by
documentation such as a police report or medical report, will be reviewed by AFC staff and will not be cause
for discharge from the services.)
I further understand that if I have a complaint against an action or inaction by my case manager, I will respectfully
discuss the issue with my case manager. If there is no resolution, I will discuss the issue further with the case
manager’s supervisor. If there is no resolution at the agency level, I will contact Cheryl Potts, Director of Care and
Quality Improvement at AFC.
If I disagree with a DRS HSP reassessment resulting in a reduction of my service hours, my case manager will assist
me in filing an appeal. I will follow through with all steps of the HSP appeal process.
I further understand that if I do not follow through with any of the above, I will be discharged from all AFC-funded
case management services immediately and will not qualify for other AFC-funded services, including transportation,
emergency financial assistance, housing and/or food vouchers.
_____________________ Cheryl Potts_________
Name Name
_____________________ ____________________
Signature Signature
_____________________ ____________________
Date Date
CASE MANAGEMENT POLICY
Program Administration and Quality Management
Subject: SOP 12 - Grievances
Date: August 27, 2007 Revised: February 29, 2008 Page 1 of 5
PURPOSE: To set a minimum standard across Cooperative agencies regarding the process of mediating and
resolving client grievances.
POLICY: The AIDS Foundation of Chicago (AFC) requires that each Cooperative agency have its own
grievance policy in place. The case manager must discuss the policy with the clients and provide
a written policy to the client upon intake. In addition, Cooperative agencies must post the
written policy and procedure in a visible area where clients can review it. If the client has a
grievance and that grievance is not resolved at the agency level after the client has followed
agency procedure, the client and case manager must adhere to the Cooperative grievance policy.
PROCEDURE:
Clients Receiving a Ryan White Funded Service
As stated above, upon intake he case manager must discuss the grievance policy with the clients
and provide a written policy to the client.
Clients may grieve the following actions/inactions:
• Failure of a case manager to act in a timely manner;
• Failure of a case manager to provide client with adequate referrals; and/or
• Case manager offends client in word or speech.
Clients may not grieve the following:
• Policies of the Cooperative that are based upon financial constraints;
• Policies of the Cooperative that are based on HRSA guidelines; and/or
• Behaviors of the client that are grounds for dismissal from case management based upon
either the agency’s Rights and Responsibilities or the guidelines listed in the
Cooperative’s Consent to Enroll forms (see SOP 11 for readmission guidelines of
terminated clients.)
In the event of a grievance, the client must first follow the procedure outlined in the agency
grievance policy. In the event that the grievance is not resolved at the agency level, the client
must then be referred to AFC’s Grievance Officer.
AFC’s Grievance Officer will ask the client if he/she has followed through with the grievance
process at his/her agency. If the client has not followed the agency’s protocols, he/she will be
referred back to the agency to address the concern. If the client has already proceeded through
the grievance process at their case management agency and is not satisfied with the outcome, the
AFC Grievance Officer will complete the Service Complaint/Inquiry form, including a complete
description of the complaint and obtaining the following information:
• Client name or name of person calling filing the grievance;
• Documentation of the client’s adherence to the grievance process at the case management
agency;
• Agency where case management services are received;
• The name of the case manager being grieved;
• The specific complaint of the client; and
• The desired outcomes of the grievance, as proposed by the client.
Where appropriate, the AFC Grievance Officer will ask the client to forward a written detail of
incidents that the client is grieving.
The AFC Grievance Officer will contact the agency’s case management supervisor within 48
business hours or the filed grievance. The case management agency will have five working days
in which to respond in writing regarding their plan to address the grievance.
The AFC Grievance Officer will discuss the situation with the client, the agency grievance
officer and/or representatives from CDPH as appropriate. Applicable policies and procedures,
client rights and responsibilities, and other documented information will influence the final
decision, which will be made by the AFC Grievance Officer. If he client and/or agency are in
disagreement with the final decision, it may be appealed through the Chicago Department of
Public Health (CDPH).
If the resolution is to transfer the client to another agency, see SOP 11 for the procedure.
Clients Receiving DRS HSP Case Management
As with Ryan White case management, upon intake he case manager must discuss the grievance
policy with the clients and provide a written policy to the client.
Clients may grieve the following actions/inactions:
• Failure of a case manager to act in a timely manner;
• Failure of a case manager to provide client with adequate referrals; and/or
• Case manager offends client in written word, speech or action.
Clients may not grieve the following:
• A reduction in service hours or termination of services based upon the Determination of
Need. DRS has an appeals process in place for these situations and the client will be
directed to file an appeal;
• Policies of the Cooperative that are based upon financial constraints;
• Policies of the Cooperative that are based on DRS HSP guidelines for services; and/or
• Behaviors of the client that are grounds for dismissal from case management based upon
either the agency’s Rights and Responsibilities or the guidelines listed in the
Cooperative’s Consent to Enroll forms (for re-admission criteria, see SOP 11.)
The remainder of the procedure will follow the guidelines given for Clients Receiving Ryan
White Funded services. However, the DRS clients can not access CCR’s mediation program
unless the grievance is in regards to a Part A service received (transportation, emergency
financial assistance, emergency food vouchers, and emergency housing assistance).
FORMS: Service Complaint Inquiry Form
AIDS FOUNDATION OF CHICAGO
NORTHEASTERN ILLINOIS HIV/AIDS MANAGEMENT COOPERATIVE
SERVICE COMPLAINT/INQUIRY
(For AFC STAFF USE ONLY)
Date of Complaint __________________ AFC Staff Taking Complaint
Client Name
Client Address
City ________________________ Zip Code ____________ Phone # (_______) _______________
Name of caller (if other than client)
Relationship to Client _________________________ Phone # (_______) _____________________
Does client receive case management services? - Yes ______ No ______
Case manager Agency
Did client receive a copy of or sign the agency grievance procedure? Yes _____ No _____
Has the client followed the agency grievance procedure? Yes ____ No ____
Service Complaint/Inquiry-Describe the nature of the complaint, include dates that the incident occurred
and all agency staff that were involved. Include any action steps client has already taken to resolve
grievance.
Page 2
ACTION TAKEN BY AFC STAFF –
Date Agency was Contacted by AFC Staff
Name of Agency Staff Contacted _______________________ Title ______________________________
Date Agency will provide written response to AFC
Date Agency responded to complaint/inquiry ______________
Final Outcome – What did the agency do to resolve the complaint/inquiry?
Is any further action required by AFC staff? Yes _____ No _____
Comments:
AFC Staff Signature
CASE MANAGEMENT POLICY
Program Administration and Quality Management
Subject: SOP 13 - Supervision
Date: March 21, 1996 (Previously SOP 6) Revised: February 29, 2008 Page 1 of 5
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the level, frequency,
and content of supervisory sessions with case managers.
POLICY: All AFC-funded case management agencies will provide basic supervision to all case managers
including but not limited to clinical and administrative oversight. All AFC-funded case
management agencies will be funded for a .25 FTE supervisor’s time to perform these duties.
Any agency that waives this funding will still be required to adhere to these supervision
expectations in order to be eligible to provide case management.
PROCEDURE: Individual agencies must provide a minimum of four hours of case management supervision per
month. Supervision can be provided individually or in a group setting. Supervision must
address client treatment coordination, service plan development, client care, case manager job
performance, and skill development. Supervision can also include individual case consultation.
The description of the supervision session must be documented in accordance with the agency
policy and be made available at utilization reviews and/or programmatic and administrative site
visits. Documentation of supervision sessions may include meeting agendas and minutes, notes
in client charts, and/or personnel files.
Case management supervisors are required to ensure regular reviews of case management charts
with no less than 100% of case manager charts reviewed on an annual basis. Case management
charts can be reviewed by supervisors, peer reviews, or agency-established quality management
teams. Quarterly review of charts is strongly recommended. Supervisory review of client charts
must be documented in the chart via a review sheet or at minimum a supervisor’s signature and
date. The documentation must also includes any deficiencies identified and the appropriate
corrective action plan.
Case management supervisors are required to attend Contract Administrators Meetings held at
AFC approximately every other month, unless there is another designated administrator at the
agency responsible for attending these meetings. Supervisors who do not attend Contract
Administrators meetings must make it a priority to keep abreast of meeting content. Case
management supervisors are also required to attend and successfully pass the Case Management
Competencies training within six months of hire/promotion into the position (see SOP 14:
Certifications and Trainings.) AFC occasionally offers supervisor-specific training opportunities;
these and all other AFC trainings are open to all supervisors and are beneficial to attend.
The case management supervisor is also required to serve as an intermediary in the grievance
procedure as outlined in SOP 12: Grievances.
It is also the responsibility of the case management supervisor to monitor each case manager’s
adherence to the required twelve (12) AFC-approved trainings annually.
Please review Exhibit A of the Ryan White Contract each contract year for additional
responsibilities of the supervisor.
FORMS:
Chart Review Summary Form
CASE MANAGEMENT RECORD REVIEW Use the following codes in documenting components in the case management service record:
“1/1” for present and required “0/1” for absent and required “0/0 or NA” for not applicable “N” for note
CRITERIA 1 2 3 4 5
Record ID# Documentation of HIV Status
Acuity score included
# Contacts (last 3 months)
Contact are consistent with acuity score
Intake date reasonable from screening date
SERVICE RECORD INCLUDES
Completed intake/assessment forms-
● Page 1
● Page 2
________
________
________
________
________
Consent to enroll-signed & witnessed
Release of information-signed & witnessed
Rights and responsibilities- signed &
witnessed
Service plan is in file
Service plan is up to date
Documentation of client enrollment in
primary care
Monitoring and intervention activities are
included in progress notes(acuity, referrals,
notes)
Linkages made are documented
ECA is included in chart with all required
documentation.
Documentation in charts of other options
used before ECA.
Progress notes reflect the payment made for
client with ECA.
Progress notes are dated
Progress notes are signed
Change of status form (date)
Reassessment every six months
(documentation otherwise)
Supervisory notes in client record
Discharge plan
COMMENTS:
TOTAL SCORE
Definition of Terms for Chart Review
Documentation of HIV Status: acceptable documentation of HIV status includes HOPWA Health
Screening Form indicating HIV infection, positive viral load lab results with the patient’s name, SSA
disability certification naming HIV, ORS certification (residual capacity), written statement from a
primary care physician, HIV antibody test results that include client’s name.
Acuity score included: case intake forms that include the acuity score format must include the acuity
score at intake for all clients.
# Contacts (last 3 months): all contacts (face-to-face, telephone, and collateral) will be counted
Contacts are consistent with acuity score: contact will be compared to the guideline for contact
based on acuity score as per the Case Management Standard Operating Policies dated September 1999.
Intake date reasonable from screening date: date of initial intake will be compared to the date of
referral to ensure timeliness of contact or contact attempts on the part of the case manager as per the
Case Management Standard Operating Policies dated September 1999.
Completed intake/assessment forms (Page 1 and Page 2): presence and completeness of both forms
will be assessed.
Consent to enroll-signed & witnessed: Consent to Enroll in Central Registry must be present in all
client charts and signed by the client and witnessed by anyone (this may include but is not limited to
the case manager).
Release of information-signed & witnessed: releases of information must be present in all charts and
documented for any collateral contact made on behalf of the client. All referrals and collateral contacts
will be reviewed for the inclusion of a release of authorization allowing contact and information
sharing to occur.
Rights and responsibilities- signed & witnessed: all client charts must include a client rights and
responsibilities that includes a clear grievance procedure and is signed by the client and witnessed
anyone (this may include but is not limited to the case manager).
Service plan in file and up to date: all charts must have a service plan that is no older than six
months without appropriate documentation detailing the reason why a service plan has not been
updated in the last six months.
Documentation of client enrollment in primary care: acceptable documentation of current client
enrollment in primary care includes a note no greater than six months old documenting case manager
knowledge of the client’s primary care provider and status of kept appointments, lab values for client
that are no greater than six months old, copies of prescriptions that are no greater than six months old,
notes reflecting accompaniment to medical appointments or coordination of transportation to medical
appointments (specified in note as based on medical need).
Monitoring and intervention activities are included in progress notes (acuity, referrals, and
notes): client charts will be reviewed to ensure that client acuity scores, referrals and linkages made,
and case notes are consistent in attempting to address client needs. When there are differences,
documentation will be sought to explain this.
Linkages made are documented: all referrals made will be reviewed to ensure appropriate
documentation is kept for all referrals (in acuity, in case notes, in service plan, in transportation and
food voucher logs, etc.).
Documentation in charts of other options used before ECA: charts for clients who have accessed
the ECA program within the last three months will be reviewed to ensure that case managers have
attempted to use other resources before they access the Title I ECA Program. For further information
please refer to the ECA Guidelines implemented in January 2000.
Progress notes reflect the payment made for client with ECA: charts for clients who have accessed
the ECA program within the last three months will be reviewed to ensure that case managers have
documented that payment was mailed or delivered to the appropriate person as per the request for
reimbursement form submitted to the AIDFS Foundation of Chicago.
Progress notes are dated: all notes must be dated with their date of contact in a legible manner.
Progress notes are signed: all notes must be signed by the case managers with full name at the end of
each individual note or initialed after each note and include full signature at the bottom of each page of
notes.
Reassessment every six months (documentation otherwise): charts will be reviewed to ensure that
reassessments are done at minimum every six months (three months for Corrections and PACPI
clients). Documentation will be sought for charts with reviews at intervals greater than six months.
Supervisory notes in client record: all client charts will be reviewed for evidence of some
administrative review. Case notes of supervisory meetings or client file reviews are acceptable
examples of documentation that will be allowed.
Discharge plan: clients with case status change forms that indicate voluntary client case closure
will be reviewed to ensure that clients are given a discharge plan prior to case closure.
CASE MANAGEMENT POLICY
Program Administration and Quality Management
Subject: SOP 14 – Certification and Training
Date: February 29, 2008 Page 1 of 15
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding standardized quality
training as well as ongoing professional development opportunities for all case managers.
POLICY: All case managers funded through Ryan White, Division of Rehabilitative Services (DRS),
Corrections, and Pediatric AIDS Chicago Prevention Initiative (PACPI) are expected to
successfully complete the AIDS Foundation of Chicago’s (AFC) Case Management
Competencies training and attend twelve (12) AFC-approved professional development trainings
annually.
PROCEDURE:
Case Management Competencies Training
All case managers providing services within the Cooperative must successfully complete AFC’s
Case Management Competencies training. In addition, in order to become a medical case
manager, the case manager must achieve certification through the training, as outlined in the
following process. Supportive services case managers must attend the training, but do not have
certification requirements.
The Competencies training exists to ensure standardization of knowledge throughout the
Cooperative with new emphasis on medical and treatment adherence. The training consists of a
full five days of training with a total of 20 modules spread throughout those days. Each module
was designed to address an area that significantly impacts case managers’ knowledge, skills, and
abilities required to provide quality services. The testing and certification process is as follows:
• Case manager will complete a pre-test on Day 1 to assess their baseline knowledge of the
information contained in the training. Case managers will receive their scores for the pre-
test, but this score will not factor into their overall training score.
• Case managers will complete post-tests after each of the 20 Modules in the Competencies
training to assess their knowledge of the content in each area.
• AFC will compile the results of all 20 Module post-test and arrive at a Total Module
Score (maximum score 283). Case managers must complete all 20 modules. Missed
training days or missed individual modules will likely result in a status of ‘Incomplete’,
thus requiring the case manager to repeat the entire Competencies training. Consistent
attendance is REQUIRED.
• Case managers will be given a take home Final Scenario Exam at the end of Day 5. This
Final Scenario Exam will assess the case manager’s competency in completing an intake,
acuity scale, data entry, service planning, and progress notes.
• Final Scenario Exams must be completed by the case manager and returned to AFC
within two weeks of training completion. Final Scenario Exams submitted late will result
in a deduction on the score – 5% for every day late. Final Scenario Exams not submitted
within two weeks of the due date will result in automatic failure.
• A team of AFC Program Staff will score Final Scenario Exams based on the
completeness and clarity of the intake, acuity scale, data entry, service planning, and
progress notes. Final Scenario Exams will be scored based on a maximum score of 283.
• Certification of case managers will be based on the combination of their Module Score
and the Final Scenario Exam.
Total Post-test Score + Total Scenario Exam Score = Certification Score
• Case managers who have a combined score of 75% or better will be certified as medical
case managers.
• Anyone who scores above 75% on the post-test scores but below 75% on the Final
Scenario Exam will have the opportunity to take a half-day service planning workshop.
After successfully completing a new Final Scenario Exam, the case manager will be
certified as a medical case manager.
• Case managers who receive an overall score less than 75%o will not be certified and will
not be permitted to provide medical case management services under the Cooperative.
However, the case manager will have one additional opportunity to demonstrate
competency by repeated the entire training. These case managers are also able to provide
supportive services case management. Supervisors will be responsible for staffing any
medical case management cases that need to be covered during this process.
• AFC will generate individualized Scoring Reports and will submit them to the case
manager and the supervisor within 3 weeks of training completion. While low individual
module scores will not necessarily require a case manager to repeat the module,
Professional Development Plans will be suggested for case managers with notably low
scores on specific modules.
Case Management Trainings
All case managers must attend a minimum of twelve (12) AFC-approved professional
development trainings annually, with one of those trainings being the MATEC Treatment
Adherence training. AFC offers a variety of continuing education and training options including
Medical Clinics, Benefits Clinics, and Large Case Manager meetings. Training calendars are
distributed to all case managers and supervisors in March of each year for the following year’s
service.
Non-AFC sponsored HIV-related trainings can count toward the required 12 trainings as long as
they have been approved by the case management supervisor prior to the event. The
Competencies Training, staff meetings, and regional coalition meetings do not count towards the
12 training requirement. The case management supervisor must submit the Training Report Form
and documentation of attendance at the training (agendas, learning objectives, etc.) to AFC
Program Staff on a monthly basis. Training attendance must be reported within one month of
attendance.
Case managers will sign in their attendance at all AFC-sponsored trainings. The case
management supervisor must submit the Training Report Form and documentation of attendance
at the training (agendas, learning objectives, etc.) to AFC Program Staff on a monthly basis (See
SOP 15 for more information on Reporting.). Training attendance must be reported within one
month of attendance. If a case manager does not report training attendance within one month of
the training, it will not be counted towards the required 12. In addition to the required training,
supervisors are strongly encouraged to keep documentation of trainings and certification
attendances in each of the case managers’ personnel files.
FORMS:
Sample Training Calendar
AIDS FOUNDATION OF CHICAGO
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE DATE: March 20, 2008 TO: All Case Managers and Case Manager Supervisors FROM: Iliana Gilliland- Program Coordinator RE: 2008-2009 Training Calendars
AFC is pleased to present the case manager training calendar for 2008-2009. In the calendar that follows we continue to attempt to meet case manager training needs, both informational and skill-related. We feel confident that this plan will meet your training needs. Should you have any additional questions, feel free to call Iliana Gilliland ext. 513.
TRAINING SCHEDULE 2008/2009 Case managers are required to attend a minimum of 12 training meetings within the contract year, between March 2008 and April 2009. These twelve may consist of any of the following trainings: 2nd Tuesday Every Three Months-Large Case Managers Meeting These large group presentations will continue to be offered every three months, and will remain three and a half hour long to continue to allow more intensive discussion and skills building. ** Please be aware of the policy regarding sign in sheets and attendance at large meetings: those
attending the meetings are expected to make arrangements to be on time and can sign in no later
than 9:30 a.m. The sign in sheets will not be available after this time. Also, case managers are
expected to sign out no earlier than 12:00 noon to receive credit for attendance at the training.
3rd Tuesday of the Month -Benefits Clinic (AIDS Foundation, 411 S. Wells) This is a voluntary group for case managers who want additional technical assistance in accessing SSI, SSA, Public Aid, and other entitlements. The group does small group problem solving and benefits consultation. Case managers will enhance their knowledge of entitlement regulations, enhance their service planning skills, and increase their confidence in doing entitlement advocacy. The group is primarily conducted by the AIDS Legal Council and Legal Assistance Foundation, and coordinated by Iliana Gilliland at AFC. They are limited to 25 case managers per session, therefore pre-registration is required. 4th Tuesday of the Month-Medical Clinic (AIDS Foundation, 411 S. Wells) This is a voluntary group for case managers who want additional information about medications, resistance to treatment, managing side effects, advances in the management of medical conditions related to HIV etc. The group does small group consultation and problem solving and they are primarily conducted by physicians and nurses from the community and coordinated by Iliana Gilliland at AFC. They are limited to 25 case managers per session, therefore pre-registration is required.
** Please be aware of the policy regarding sign in sheets and attendance at Benefits Clinics and
Medical Clinics: those attending the meetings are expected to make arrangements to be on time and
can sign in no later than 9:30 a.m. The sign in sheets will not be available after this time.
DRS Update Trainings These are quarterly discussions of current issues regarding DRS case management coordinated by Jim Elsbury from AFC. The dates for those are: June 6-2008, September 5-2008, December 5-2008, March 6-2009. They are limited to 25 case managers per session, therefore pre-registration is required. AFC Conferences Service Provider Council seminars are offered periodically and will be announced the previous month. Case Managers must participate in the complete event to obtain training credit for these conferences. MATEC Trainings These intensive trainings are offered by MATEC and combine the latest on HIV and guidelines for managing patients with HIV disease. Pre-registration is required for all programs and they are offered at no cost to case managers from Title I funded agencies. For information regarding these programs and to register, please call Alicia Mc Donald at 312-996-1373 or go to www.matec.info TPAN Trainings These trainings are offered by Test positive Aware Network in collaboration with Haymarket Center. Each program will offer an educational forum and CEU’s. Registration fee and RSVP required. For more information regarding these programs and to register please call Barbara Marcotte at 773-989-9400 or [email protected] Non-AFC Sponsored Training Events Case managers are allowed credit for trainings not facilitated by the AIDS Foundation of Chicago, counting toward their requirement. These meetings, however, need to be properly documented by submitting a copy of the agenda to Iliana Gilliland for approval. Emergency Training Events On rare occasions, AFC Staff are required to hold mandatory all case manager meetings to share time-sensitive case management information. These meeting will never exceed twelve hours in a 30-day time period (as per the Case Management Contract Exhibit) and will count toward the twelve professional development sessions per year.
AIDS Foundation
OF CHICAGO NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT
COOPERATIVE
CASE MANAGER TRAINING CALENDAR Large Case Manager Trainings
April 2008– March 2009
DATE TIME EVENT TOPIC LOCATION June 10-2008 9:00–1:00 PM HIV Medical update
(Sponsored by Pfizer)
• New treatments and side effect management
• Helping support client adherence • Simplifying HAART regimens • Adapting HAART treatments • Update on New ARV’s • TMC-125 and CCR-5
TBA
Sept 9-2008 9:00–1:00PM HIV and STDs (Sponsored by Gilead)
• Statistics and facts • STDs 101 • How STDs exacerbate HIV infection • Negotiating safer sex techniques
TBA
Dec 9-2008
9:00-1:00PM
Mental Health training (By Dr. Rodger MacArthur-Detroit Medical Center-Sponsored by Roche)
• Practical skills in dealing with clients with chronic mental illness
• The nature of the most prevalence co-occurring mental illnesses
• Recognizing mental illness • Stigma and how disease process
interferes with HIV medication • Strategies for working with doctors,
psychiatrists and pharmacists to improve adherence
• Role case managers play in Mental Health
TBA
March 10-2009 9:00-1:00PM “Substance Abuse and HIV” (By Kenis Williams-Assistance Program Director of Haymarket Center and Alan Amberg-Regional HIV Specialist-Walgreens Specialty Pharmacy)
• Practical skills in dealing with substance abuse clients
• Substance abuse 101 • Street drugs and HIV meds • Recovery models • Strategies to improve adherence
TBA
AIDS Foundation
OF CHICAGO NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT
COOPERATIVE
Medical Clinics April 2008– March 2009
DATE TIME EVENT TOPIC LOCATION April 22-2008 9:00-11:00 am “Introduction to Transgender
Health and Medicine” (By Alan Amberg-Regional HIV Specialist-Walgreens Specialty Pharmacy and Drew Halbur, Pharmacy Manager-Walgreens at HBHC)
• What is transgender? Language, prevalence, etc
• Some key health and social issues in Transgender care
• What are the hormones therapies commonly used in gender reassignment? Costs, coverage and concerns
• Where can you go for more help in serving these patients?
AFC
May 27-2008 9:00-11:00 am “A New Class a New Option: Understanding CCR5 Antagonists and Selzentry” (By Dr. Olga Lugo Torres-Sponsored by Pfizer)
• Mechanisms of action • Choosing the right patient • Tolerability, safety, dosing
AFC
June 24-2008 9:00-11:00 am “Understanding ARV Resistance in the Treatment Experiences HIV Patients” (By Susan Laney-Community Affairs Manager Boehringer-Ingelheim)
• Factors that increase the likelihood of
treatment failure • Implications of ARV resistance • Principles of drugs resistance • Resistance testing-Types and
Interpretation • Genotypic and Phenotypic Tests
AFC
July 22-2008 9:00-11:00 am “Sexual Orientation and Implications for Case Management” (By Alan Amberg-Regional HIV Specialist-Walgreens Specialty Pharmacy)
• What is sexual orientation • How do people identify and what does
it mean for their social and sexual networks?
• What are some of the differences in different racial and ethnic groups?
• What are some of the psychosocial issues that manifest in health concerns?
• What are the key health concerns and implications for the case manager
AFC
Aug 26-2008 9:00-11:00 am “When Should I Start Taking my Meds” (By Jean Lee-Pharm D-Sponsored by Roche)
• Understanding your CD4 count and when to initiate medications
• Understanding mechanism of action of different class of drugs
• Why we use medications from different classes to treat HIV?
• Importance of adherence to treatment • New drugs and their importance in
HIV
AFC
Sept 23-2008 9:00-11:00 am “Action Points” (By Jackie Kerns-HIV Community Liaison-Sponsored By Pfizer Inc)
• Discuss how a personal health inventory can help HIV+ patients and their health care providers develop a tailored treatment plan
• Identify critical questions to ask health care providers when selecting an HIV drug regimen
• Discuss how to develop a treatment plan to manage HIV and balance safety concerns
• Build skills to support effective communication with healthcare providers
AFC
Oct 28-2008 9:00-11:00 am “Drug to Drug Interactions” (By Nick Olson-Pharm D-Bioscript Pharmacy- Sponsored by Roche)
• HIV medications with “play drugs” • HIV medications and interactions • With supplements • HIV medications and over the counter
medications • HIV Medications and side effects
AFC
Nov 25-2008 9:00-11:00 am
“How to Talk to your Doctor” (Sponsored by Gilead)
• Empower your clients to talk to their physicians
• How to request different/new medications
• Writing down questions to ask your medical provider before your appointment
• Help clients to prioritize questions and concerns before their appointments
AFC
Jan 27-2009 9:00-11:00 am “Major Depression and HIV” (By John D. Moore, LCPC, CADC)
• Assess how depression impacts persons living with HIV
• Explore how seasonal changes can increase depressive symptoms in the HIV population
• Examine how to help your clients work through depression
• Uncover how various street drugs can make depression worse in those living with HIV
AFC
Feb 24-2009 9:00-11:00 am “Women and HIV” ( Panelist Sponsored by Walgreens Specialty Pharmacy)
• Update on HIV care for pregnant women and children
• Women and barriers to care • Psychosocial issues and implications
for case management
AFC
March 24-2009 9:00-11:00 am “Mental Health Issues in HIV Patients” (By Susan Laney-Community Affairs Manager- Boehringer Ingelheim))
• Statistics • Depression and HIV related mortality • Mental Health and adherence to
antiretrovirals • Mental health screening and initiation
of HAART • Considerations for treatment
decisions • Psychotropic medications and
interactions with ART
AFC
AIDS Foundation
OF CHICAGO NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT
COOPERATIVE
Benefits Clinic April 2008– March 2009
DATE TIME EVENT TOPIC LOCATION April 15-2008 9:00-11:00 am “Service Planning, Re-Assessment
and Documentation” (By Korrey Kooistra and Iliana Gilliland-AFC)
• Selection of services and interventions that will help meet the identified medical and social needs
• Addresses long term and short term goals
• Writing goals and objectives • Documentation must • Essential client record/chart
elements
AFC
May 20-2008 9:00-11:00 am “Screening, Intake and Acuity” (By Jim Elsbury and Angela Jordan-AFC)
• Establishing the level of care on the client eligibility
• Determine basic assessment of clinical and psychosocial needs
• Intake information gathering • Scoring of client medical and
psychosocial needs
AFC
June 17-2008 9:00-11:00 am “Confidentiality, Consent and Grievance Procedure” (By Justin Hayford-AIDS Legal Council and Jim Elsbury-AFC)
• The AIDS Confidentiality Act • Differences between the AIDS
Confidentiality Act and HIPAA • Mandatory consent forms • Grievance Procedure Process
AFC
July 15-2008 9:00-11:00 am “Emergency Service Resources” (By Ric Martel-AFC)
• Emergency Financial Assistance, policies and procedure
• Homeless Prevention Funds, policies and procedures
• Transportation, policies and procedures
AFC
Aug 19-2008 9:00-11:00 am “Medicaid/Medicare/ Medicare Part D/Spend Down” (By Alan Amberg-Walgreens Specialty Pharmacy)
• Eligibility criteria • Other help with health care cost • All about Medicare Part D program • What changed in 2008 • What’s on the horizon for changes in
2009
AFC
Sept 16-2008 9:00-11:00 am “All kids Program” (IDPH-All kids Program)
• Eligibility criteria • How to apply • Policies and Procedures
AFC
Oct 21-2008 9:00-11:00 am “Health Benefits for Workers with Disabilities” (By John Spears-Director HFS-HBWD Program)
• Who is eligible • How to apply • Income Limits • How much will it cost
AFC
Nov 18-2008 9:00-11:00 am “Back to Work” (By Greg Braxton-Chicago House)
• The biases of going back to work for people with HIV
• SSI/SSDI and going back to work • Employment Programs • The history of I-4
AFC
Jan 19-2009 9:00-11:00 am “Aging services for HIV” (Panelist sponsored by HIV and Aging SPC committee)
• Describe services provided to older adults by the Chicago Department of Senior Services (DOSS), the Illinois Department of Aging and other agencies serving elders
• Identify opportunities for collaboration between HIV case managers and colleagues in community agencies serving elders.
AFC
Feb 17-2009 9:00-11:00 am “Corrections Initiative/Benefits Behind Bar” (By Cynthia Tucker from AFC and AIDS Legal Council)
• Eligibility criteria • Ex-convicts and the work force • Ex-convicts and benefits • Expungement
AFC
March 17-2009 9:00-11:00 am “SSI/SSDI” (By Ron Castan-Legal Assistance Foundation)
• Eligibility Criteria • Application Process
• Appeal Process
AFC
MATEC Midwest AIDS Training and Education Center
DATE TIME EVENT TOPIC LOCATION March 24 and 25, 2008
June 2 and 3, 2008
Two-day program (Counts for
two of the 12
mandatory
meetings)
Multidisciplinary Core Seminar: • HIV epidemiology, pathogenesis and
course of infection
• Clinical manifestations of HIV and treatment guidelines
• Common legal, emotional and psychosocial issues that affect patient care
• Cultural competence in the care of HIV infected patients
Contact MATEC for information.
May 20, 2008
One-day Program (Counts for
one of the 12
mandatory
meetings)
HIV Prevention and Test Counseling: • Assessing a patient’s risk for HIV
infection
• Identifying ways patients can reduce the risk of HIV Transmission
• Client-centered techniques for discussing HIV prevention and testing
• Key components of HIV pretest and posttest counseling
Contact MATEC for information
May 28, 2008 Half day program (Count for one of
the 12 mandatory
meetings)
HIV Test Counseling Practicum: Participants must attend the HIV Prevention and Test Counseling workshop listed above to be eligible for this program.
• Identifying elements of HIV pretest and posttest counseling
• Applying client-centered counseling techniques to HIV test counseling with simulated clients
Contact MATEC for information
June 10, 2008 One-day Program (Counts for
one of the 12
mandatory
meetings)
Adherence Counseling: A Client-Centered Approach:
• Factors that affect adherence to drug treatment regimens
• Drugs used in HAART regimens and their side effects
Contact MATEC for information
• Client-centered counseling approaches and techniques
• The RIME/EARS model for effective adherence counseling
June 18, 2008 Half day Program (Count for one
of 12
mandatory
meetings)
Adherence Counseling practicum: Participants must attend the Adherence Counseling Workshop listed above to be eligible for this program.
• Identifying elements of the RIME/EARS Model for adherence counseling
• Applying client-centered counseling techniques to adherence counseling with simulated clients
Contact MATEC for information
April 8 and 9, 2008
Two-day Program (Counts for
two of the 12
mandatory
meetings
Cultural Competence in HIV Care:
• Honoring diversity • Culture and cultural
competence • How we learn about culture • How cultural issues affect
patient care • Skills for cultural competence • Capacity –building for
providers
Contact MATEC for information
April 22, 2008 One-day Program (Counts for
one of the 12
mandatory
meetings)
Prevention with Positives: • Concepts of behavior change in
adults and adolescents • Using communication skills to build a
collaborative patient • How to conduct brief motivational
counseling sessions to encourage behavior change
• How to help patients adopt safer sex practices and improve their HIV disclosure skills
Contact MATEC for information
Pre-registration is required. For information, call Alicia Mc Donald at 312-996-1373 or go to www.matec.info
TPAN Test Positive Aware Network
Committed to Caring 2008 Schedule
DATE EVENT TOPIC LOCATION March 28, 2008 Substance Abuse and Violence: How do
they Intersect? Contact TPAN for Information
April 25, 2008 The Stages of Change: Client Centered Services
Contact TPAN for Information
May 30, 2008 Substance Abuse Seminar: Pharmacology/Physiology
Contact TPAN for Information
June 27, 2008 Depression and HIV Contact TPAN for Information
July 25, 2007 Substance Abuse Seminar: MISA Contact TPAN for Information
August 29, 2008 Treatment Adherence Strategies Contact TPAN for Information
Sept 26, 2008 Substance Abuse Seminar: Crystal Methamphetamine Update
Contact TPAN for Information
October 31, 2008 How to Address High Risk Sexual Behavior in HIV + Individuals
Contact TPAN for Information
Nov 21, 2008 Substance Abuse Seminar: The Disease Concept
Contact TPAN for Information
Dec 12, 208 Empowering HIV+ Women Towards Self Care
Contact TPAN for Information
For information please call Barbara Marcotte at 773-989-9400 or [email protected]
AIDS Foundation
OF CHICAGO NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT
COOPERATIVE
2008-2009 Training Calendars
Large
CM
Benefits Clinic
Medical Clinic
RW Orientation (New CM)
DRS (New CM)
DRS Update
Housing
Jan/08
1/15/08
1/22/08
Jan 3, 4 & Feb 1/08
1/24/08
Feb/08
2/19/08
2/26/08
Feb 6, 13,20,27 and March 5/08
2/28/08
March/08
3/11/08
3/18/08
3/25/08
3/7/08
3/27/08
April/08
4/15/08
4/22/08
April 3, 4 & May 2/08
4/24/08
May/08
5/20/08
5/27/08
May 7, 14, 21, 28 and June 4/08
June/08
6/10/08
6/17/08
6/24/08
6/ 6/08
July/08
7/15/08
7/22/08
June 26, 27 & Aug 1/08
Aug/08
8/19/08
8/26/08
Aug 6, 13, 20, 27 and Sept 3/08
Sept/08
9/9/08
9/16/08
9/23/08
9/5/08
Oct/08
10/21/08
10/28/08
Oct 2, 3 & Nov 7/08
Nov/08
11/18/08
11/25/08
Nov 5, 12, 19, 26 and Dec 3/08
Dec/08
12/9/08
12/16/08
-----------
12/5/08
Jan/09
1/20/09
1/27/09
Jan 8, 9 & Feb 6/09
Feb/09
2/17/09
2/24/09
Feb 4, 11, 18, 25 and March 4 3/08
March/09
3/10/09
3/17/09
3/24/09
3/6/09
CASE MANAGEMENT POLICY
Program Administration and Quality Management
Subject: SOP 15 - Reporting
Date: February 29, 2008 Page 1 of 9
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the timely reporting of
information on case management service utilization to the AIDS Foundation of Chicago (AFC).
POLICY: All subcontracted case management agencies are required to submit monthly service utilization
data to AFC. Agencies are required to use a narrative format as well as client-level data entry
into AFC’s data system. Reporting is utilized to hold subcontractors accountable for services as
well as to monitor quality management efforts.
PROCEDURE: By the tenth (10
th) of every month, subcontracted agencies are required to submit all encounter
data and service utilization information for the previous month. Monthly reporting occurs
through two mechanisms: direct data entry of case management encounters into AFC’s client-
level data system, and the completion of the monthly report and narrative.
All client encounters must be entered into the client-level data system. It is left to individual
agency decision as to how and when encounters get entered into the system (i.e. at the time of the
encounter or in aggregate once a month). However, all encounters must be entered no later than
the 10th
for the previous months services.
Each subcontracted agency is required to submit to AFC program staff a monthly report. This
report includes aggregate information on number of clients receiving services, number of new
clients by case management type, caseloads by case manager, and number of encounters by type.
The narrative includes personnel and program changes, quality improvement activities, Training
Report Form, and technical assistance needs.
Agencies receiving Part B case management funding are required to submit quarterly reports as
well. On those months when a quarterly report is submitted, the monthly report does not need to
be submitted. Monthly encounters must still be entered into the data system.
The timely submission of monthly reports will be taken into consideration during AFC-
conducted site visits, and the failure to submit reports on time may impact the subcontracted
agency’s future funding.
FORMS:
Part A and Part B Monthly Report Narrative
Part B Quarterly Report Training Report Form
AIDS FOUNDATION OF CHICAGO
INSTRUCTIONS FOR COMPLETING THE CASE MANAGEMENT-Part A & B MONTHLY REPORT
Effective 6/2004
NARRATIVE REPORT AGENCY __________________________________________________ MONTH ___________________________ YEAR _______________ NAME OF PERSON COMPLETING REPORT _________________________________ (Please submit one report per agency per month along with your client level data report) TOTAL # CLIENTS RECEIVING SERVICES ___________
(Total number of active clients receiving case management services in the HIV/AIDS case
management program in this past month) TOTAL # OF NEW Ryan White CLIENTS THIS MONTH ____________
(Total number of clients newly referred for Ryan White case management in this past month,
regardless of whether an intake has been completed) TOTAL # OF NEW ORS CLIENTS THIS MONTH ____________
(Total number of newly referred ORS customers in this past month)
CASELOAD NUMBERS PER CASE MANAGER (Feel free to add lines as necessary, or append a separate sheet)
RW ORS CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________
Any additional questions or needs for clarification or support, feel free to contact your Program Associate
at 312.922.2322.
This report is due on the tenth of every month along with an electronic client level reporting spreadsheet. When the tenth falls on a weekend or holiday, the report is due the following business by 5PM close of business.
NARRATIVE PAGE 2
Describe any program or agency changes that have occurred in the last month and their potential impact on case management services. Please describe any organizational changes that may affect your agency=s case
management services.
Describe any administrative problems/changes and how they may have impacted service delivery, include strategies utilized to address them. Include personnel changes in this section. Please describe any difficulties your HIV/AIDS or case management program has
encountered in the administration of its programs and how you will address them. Please
update as well as to the personnel changes in your case management program. Include
name of previous case manager, resignation or termination, status of new hire, names of
any new hires and who they replace, and start date.
Describe any quality assurance/improvement activities related to HIV case management which occurred in this month. Describe any surveys, advisory board meetings, chart reviews, etc. implemented to
improve and ensure the quality of the case management services.
List any trainings or seminars staff have attended to improve HIV case management services. Staff Position Type of training Date Other than AFC sponsored training, please list the professional development
opportunities offered to case management staff. Include leadership development
training for lead staff as well.
Describe any technical assistance needs for programmatic issues or operations.
Please detail any needs for support in your case management program. Also feel free to
provide us with feedback on trainings, orientations, meetings, our responses to your
requests for HOPWA, ECA, etc. Additional comments: …\Manual\monrept62004.doc
AIDS FOUNDATION OF CHICAGO CASE MANAGEMENT-Part A & B MONTHLY REPORT
AGENCY __________________________________________________ MONTH ___________________________ YEAR _______________ NAME OF PERSON COMPLETING REPORT _________________________________ TOTAL # CLIENTS RECEIVING SERVICES ___________ TOTAL # OF NEW Ryan White CLIENTS THIS MONTH ___________ TOTAL # OF NEW ORS CLIENTS THIS MONTH ___________
CASELOAD NUMBERS PER CASE MANAGER RW ORS
CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________ CASE MANAGER ______________________________ NUMBER ________
Describe any program or agency changes that have occurred in the last month and their potential impact on case management services. Describe any administrative problems/changes and how they may have impacted service delivery, include strategies utilized to address them. Include personnel changes in this section. Describe any quality assurance/improvement activities related to HIV case management which occurred in this month.
CASE MANAGEMENT MONTHLY REPORT Page 2 List any training or seminars staff have attended to improve HIV case management services. Staff Name & Position Type of training Date Describe any technical assistance needs for programmatic issues or operations. Additional comments:
Part B – Direct Services NARRATIVE
Agency______________________ Quarter_____________
ACCOMPLISHMENTS
Provide a description of the services provided.
BARRIERS/TRENDS
Describe any program/administrative or agency problems/changes that have occurred in the last quarter and their potential impact on agency HIV/AIDS direct services. Include personnel changes in this section. Describe any barriers impeding service delivery. Describe agency strategies utilized to address them.
Q/A and TRAINING
Describe any quality assurance/improvement activities related to HIV/AIDS direct services which occurred in this quarter. List any trainings or seminars staff have attended to improve agency HIV/AIDS direct services. *Include participation in SPC activities, forums, seminars. Staff Position Type of training Date Describe any technical assistance needs for programmatic issues or operations. Additional comments:
TRAININGS REPORT
STAFF
NAME AND
POSITION
TRAINING
TITLE
TRAINING
DATE
Number of
Hours
Number of
Sessions
PRESENTER
TYPE
TYPE: Please select one of the following
- AFC-CONF: AFC conference
- BC: Benefits Clinic
- CHHP: CHHP
- CORR: Corrections
- DRS: DRS Updates
- Housing
- Large: Large Case Managers Training
- MC: Medical Clinic
- Other AFC
- Outside: Trainings Outside AFC
- PACPI: PACPI Program
NOTE: Please send the copy of the agenda for ALL trainings outside AFC
you have listed in this report
CASE MANAGEMENT POLICY
Program Administration and Quality Management
Subject: SOP 16 – Quality Management and Technical Assistance
Date: April 1996 Revised: February 29, 2008 Page 1 of 3
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the development and
application of quality management standards of practice to ensure that HIV case management
services will be of uniform high quality and provide a systematic method of evaluating and
improving services to clients, subcontractors, and funders.
POLICY: The AIDS Foundation of Chicago (AFC) requires that every case management agency maintain
and adhere to a comprehensive quality management plan. The adequacy, appropriateness, and
effectiveness of case management services will be routinely assessed and measured to assure
high quality. All quality management plans must include mechanisms to ensure that findings
will be utilized to improve the quality of these services. AFC will provide reasonable technical
assistance will be made available to any subcontractor to achieve strong individualized quality
management plans.
PROCEDURE:
Definition and Overview of Quality Management
AFC and the Cooperative are committed to providing persons with HIV/AIDS high quality
social and medical coordination services designed to meet their individual and collective needs.
The commitment to excellence by subcontractors in the provision of case management services
is critical in order to assure the continued availability of quality HIV/AIDS services in the
greater Chicago area.
The primary objective of the Cooperative’s case management quality management program is to
promote improved client outcomes through:
• Facilitating the ability of subcontractors to meet client needs;
• Facilitating ongoing improvements of case management practice;
• Adhering to established HRSA quality management performance indicators and
standards;
• Supporting and complementing agency goals;
• Assisting in expanding the service capacity of subcontracted agencies;
• Promoting consistency of intra- and inter-agency case management services; and
• Assuring the long-term viability of HIV/AIDS-related services in the greater Chicago
area.
Elements of Case Management Cooperative Quality Management Program
The case management quality management program consists of five different elements:
1) Agency/program quality management plan
2) Case management agency profile
3) Client satisfaction surveys
4) AFC-conducted agency site visits and administrative review
5) Agency-submitted monthly report data and narratives
Case management agency profiles include service utilization data, outcome indicators, process
indicators, and structure indicators. AFC staff will conduct and tabulate these profiles in order to
ensure parity of services throughout the system. AFC monitors each of these elements through
real-time data entry into the client-level database (SOP 10: Direct Data Entry), ongoing reporting
(SOP 15: Reporting), and site visits (SOP 17: Site Visits). All agency data collected in these
profiles are confidential and only for the use of AFC’s quality management development.
AFC conducts Cooperative-wide client satisfaction surveys annually (SOP 18: Client
Satisfaction Surveys). Case management agencies must identify and utilize mechanisms to use
results of client satisfaction or other survey to improve services.
AFC Program Staff and Case Management Governance members will conduct formal
administrative review of all subcontracted agencies via site visits (SOP 17: Site Visits). Agencies
must develop a time-specific plan for addressing any identified areas of deficiencies in an effort
to improve an agency’s performance scores and services.
All subcontracted agencies must submit monthly report data and a monthly narrative (SOP 15:
Reporting). AFC program staff will utilize the information submitted in these monthly reports to
hold agencies accountable, monitor service delivery, and make suggestions related to quality
management as appropriate. AFC strongly recommends that agencies utilize monthly reports
internally in the same ways.
Quality management assistance is provided via ongoing case manager trainings, the publication
and dissemination of organizational and governmental guidelines and program standards, and the
provision of individualized technical assistance upon request. AFC will meet with case
management agencies to assist with the development of a quality management plan.
Subcontractor Expectations and Technical Assistance
All Cooperative subcontractor agencies are required to have a formal quality management plan
in place. Agencies should consult the HIV/AIDS Bureau (HAB) Quality Management Manual
and HRSA’s Performance Standards as a basis for outcomes and measures. Individual quality
management plans should reflect a commitment to established performance indicators, especially
related to the collaboration of primary medical care, other medically-related services, and case
management. AFC will utilize funder requirements and national best practices to establish
benchmarks for these indicators.
To assist subcontractors in the provision of efficient and effective case management services,
AFC will provide technical assistance upon request to any subcontractor experiencing challenges
in developing and/or implementing a quality management plan.
The case management supervisor at a Cooperative subcontractor can request, in writing, AFC
consultation and technical assistance regarding any aspect of quality management including
program and/or administrative issues. Requests for assistance can be directed to the designated
Program Staff members at AFC. The staff will acknowledge the request and will respond to the
request within 20 business days.
FORMS:
CASE MANAGEMENT POLICY
Program Administration and Quality Management
Subject: SOP 17 – Site Visits
Date: March 21, 1996 (Previously SOP 10) Revised: February 29, 2008 Page 1 of 21
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding quality of case
management service provision through a consultative certification process that centers on
enhancing the lives of persons served by ensuring appropriate documentation, eligibility, and
service planning.
POLICY: The AIDS Foundation of Chicago (AFC) will conduct annual site visits to all case management
agencies to ensure that they adhere to the basic standards of care outlined in the standard
operating procedures (SOP) and maintain a quality case management program. Problems found
in site visits must be corrected by the case management agency and may impact future funding.
PROCEDURE: Site visits will be a joint AFC and peer review conducted annually at all case management
agencies by AFC Program Staff and Case Management Governance committee members. Site
visits will include several steps: an agency interview and survey, a review of client charts, and a
collaborative debriefing session. AFC will schedule the site visit and provide the agencies with at
least 30 days notice. At the point of scheduling, AFC will provide the case management
supervisor with the requisite forms and checklists that will assist with preparation.
The agency interview and survey assess the case management agency’s adherence to a set of
standards based on the case management SOPs. Agencies will be required to provide both verbal
explanations of their activities as well as documentation of standards met to achieve full points in
this section. Case management supervisors and/or program administrators will receive the
survey ahead of time and are requested to collect documentation for each item in advance. It is
estimated the interview and survey may take up to two (2) hours.
The site reviewers will randomly select and review approximately 10% of the agency’s files
(minimum of 10 and maximum of 50). Files will be reviewed utilizing the Record Review form,
which will be distributed to agencies ahead of time. It is estimated the review of files may take
up to 3 hours.
Site visits will conclude with a debriefing session where AFC and peer reviewers will share
initial findings, acknowledge successes in service delivery, and develop an agreed upon time-
specific plan for addressing any identified areas of deficiencies in an effort to improve an
agency’s performance scores. Agencies may dispute or request clarification of the results of a
site visit within 30 days of the agencies’ receipt of the site visit report.
Site visit scores and the ability of an agency to address deficiencies in a timely manner will
influence future funding decisions of case management services. Agencies are strongly
encouraged to take site visits seriously, as low scores may result in the reduction or loss of future
funding.
FORMS:
Site Visit Packet Letter
Site Visit Survey
Record Review Form
AIDS Foundation O F C H I C A G O
411 South Wells Street Tel (312) 922-2322 Suite 300 Fax (312) 922-2916 Chicago, IL 60607 TDD (312) 922-2917
August 19, 2005
Dear Case Management Supervisor:
Enclosed please find the site visit schedule for the 2005 cycle. This year’s site visit program will again use the
Certification Process. Included below are both the Certification Survey Form that AFC staff will complete,
followed by the Agency Response Form, which staff will review at the site visit. There is also a questionnaire
for an interview with the case management team and a chart review for each agency. The scores of both Survey
Forms and the score from the chart review will be totaled up and a percentage score given based on total points
scored and total points available. The score will be used to determine the certification status of continuing
agencies in relation to its HIV case management program. If funding for Title I Case Management is reduced,
continuing agency certification status could be a factor in future agency funding levels.
The service delivery aspect of the HIV/AIDS case management program will follow the enclosed questionnaire
format. It is anticipated that the interview for both the questionnaire and the Certification Survey will last
approximately three to four hours. After the interview portion of the site visit, AFC Program Staff will
randomly select and review approximately 10% of the agencies files (minimum of 5 and maximum of 50). We
anticipate that this will last approximately two to three hours depending on the size and caseload of the agency.
Finally, the AFC Program Staff and agency case management staff will meet to review the results of the
questionnaire and the chart review. The final debriefing will consist of acknowledging successes in service
delivery, and agreeing to a time-specific plan for addressing any identified problem areas in an effort to improve
an agency’s performance scores.
Thank you in advance for your hospitality. I look forward to a great case management certification program,
should you need to reschedule your site visit please contact your Program Associate. If we do not receive any
communication to the contrary, we will assume that the date is fine and will look forward to meeting you at
the scheduled time.
Thank you,
Jim Elsbury
Program Manager
Northeastern Illinois HIV/AIDS Case Management Cooperative
Goal
The goal of the Northeastern Illinois HIV/AIDS Case Management Cooperative Quality Certification
process is to promote the quality, value, and optimal outcomes of services through a consultative
certification process that centers on enhancing the lives of the persons served.
Purposes
In support of our mission, vision, and values, Northeastern Illinois HIV/AIDS Case Management
Cooperative’s purposes are:
• To develop and maintain current, field-driven standards that improve the value and
responsiveness of the programs and services delivered to people in need of case management
and other services delivered to people in need of case management and other life enhancement
services.
• To recognize those organizations which achieve certification through a consultative peer-
review process and demonstrate their commitment to the continuous improvement of their
programs and services with a focus on the needs and outcomes of people living with HIV.
• To conduct case management research emphasizing outcomes measurement and management,
and to provide information on common program strengths as well as areas needing
improvement.
• To provide consultation, education, training, and publications that support organizations in
achieving and maintaining certified programs and services.
• To provide information and education to consumers and other stakeholders on the value of case
management certification.
• To seek input and to be responsive to consumers and other stakeholders.
Vision
Through responsiveness to a dynamic and diverse environment, the Northeastern Illinois HIV/AIDS
Case Management Cooperative serves as a catalyst for improving the quality of life of the persons
served by Northeastern Illinois HIV/AIDS Case Management Cooperative- certified organizations and
the programs and services they provide.
Ryan White Case Management 2005 Site Certification Survey
QUALITY STANDARD 1: Services available are culturally sensitive and competent with regard to language, culture, spirituality, sexual orientation, age, gender, race, etc.
present
Indicator 1.1 Outreach is targeted to specific communities of need in a manner that is consistent with community culture. Evidence:
• Client input in service delivery through participation in advisory board (Case Management Governance), and so on is documented.
• Promotional information is easily understood by all people and is oriented to target specific communities.
• Other:___________________________________________________________
Indicator 1.2 Services are conducted in a language/method that is sensitive to the communities served and case managers are aware of assisting clients in identifying issues that may be affected by race, primary language, sexual orientation, age, gender, disability, communities identified with, family needs and customs.
Evidence: • Intake formats provide opportunity for clients to discuss barriers to care specific to
their culture and needs. • Case managers are trained in addressing and assessing needs for specific
communities. Onsite documentation is available. (To be reviewed) • Other:________________________________________________________________
Indicator 1.3 Staff are competent at serving their target populations. Evidence:
• Resumes on file reflect previous experience with and educational about diverse populations. (To be reviewed)
• Case managers attend trainings that address diverse community issues. On site documentation is available. (To be reviewed)
• Other:_________________________________________________________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
QUALITY STANDARD 2: Services are offered in such a way as to overcome barriers to access and utilization.
Indicator 2.1 Services are accessible by all means of transportation. Evidence:
• Services are accessible by all means of transportation. • Alternate services sites or referral sources are maintained that are geographically
sensitive to clients needs. Demonstration is made for necessary services through memorandums of agreement or linkage agreements. (To be reviewed)
• Annual client survey indicates satisfaction with program site. Agency has demonstrated participation in AFC client satisfaction survey. (To be reviewed)
• Other_____________________________________________________________
Indicator 2.2 Supportive accommodations are made. Evidence:
• There is documentation that transportation resources are available to eligible clients to facilitate clients receipt of case management services.
• Agency provides home visits as needed and clinically indicated and appropriate documentation is maintained.
• Special transportation needs are assessed and made available to clients. Charts document assessments for transportation.
• Other_______________________________________________________________
Indicator 2.3 Services site is physically accessible to persons living with HIV. Evidence:
• ADA is complied with: accessible entrances with clear language, accommodations for people with visual or hearing impairments.
• Translation services are utilized when necessary and chart documentation supports client assessments.
• Other__________________________________________________________________ Indicator 2.4 Services are offered in a timely fashion, both in terms of service hours and in terms of reasonable length of time between referral and initial contact. Evidence:
• Response time for new referral is appropriate for the level of care indicated at time of referral.
• Frequency of ongoing contact is based on client level of need and need for care.
• Reassessments are done in a timely fashion and indicate any changes in client level of need for need for care.
• Procedures are in place to ensure clients have access to information regarding services in case of emergencies 24 hours a day. (To be reviewed)
• Other_________________________________________________________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Quality Standard #3: Case managers and other agency staff maintain and uphold client rights and client confidentiality.
Indicator 3.1 Staff and clients review agreement regarding client rights and responsibilities, and a signed receipt of the statement is in client file.
Evidence: • Review of client file indicates compliance. • Other__________________________________________________________________
Indicator 3.2 Staff and clients review agency policy regarding methods of chart access, and a signed receipt of the policy in client file.
Evidence:
• Review of client file indicates compliance. (To be reviewed) • Other__________________________________________________________________
Indicator 3.3 There is a signed release of information for every collateral or third-party contact in client file. Evidence:
• Review of client file indicates compliance. • Other__________________________________________________________________
Indicator 3.4 Clients will be informed at intake, of eligibility criteria, grievance procedures, description of agency services, and the right to participate in agency client advisory board or client input forms, when applicable. Evidence:
• Review of client file indicates compliance. • Other__________________________________________________________________
Indicator 3.5 There is a forum for client input at the agency (i.e. focus groups, client advisory board, client surveys).
Evidence:
• Review of client file indicates compliance. • Other__________________________________________________________________
Indicator 3.6 Client records are kept in lockable file cabinets, and computer information is appropriately secured. Evidence:
• Facility tour indicates compliance.
• Other____________________________________________________________
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Quality Standard #4: Services are professional, clinical and adhere to the standards set by the Northeastern Illinois HIV/AIDS Case Management Cooperative Governance.
Indicator 4.1 Case managers are trained through the Cooperative orientation and receive certification upon completion.
Evidence:
• Documentation is on file at the AIDS Foundation. • Other__________________________________________________________________ Indicator 4.2 Case managers are supported in professional and personal development to maintain service abilities. Evidence:
• Case managers have adequate vacation, bereavement leave, and personal leave through agency policies. (To be reviewed)
• Case managers have regular supervision with attention to burnout as indicated through policies and reviewed at annual site visits.
• Case managers have annual in-services on self-care, physical and emotional. • Agency assesses case managers needs for ongoing education, including skill
development and informational needs to serve people with HIV. Documented by attendance records.
• Training for case managers includes annual updates about basic HIV medical information, especially targeting specific populations at risk, i.e., women with children, elderly, etc.
• Other__________________________________________________________________ Indicator 4.3 There is documentation that a case manager has attended a minimum amount of ongoing training to provide case management services through the Cooperative for the previous year. Evidence:
• Review of staff training records indicates compliance. (To be reviewed) • Other__________________________________________________________________
Indicator 4.4 Job descriptions for case managers are on file. Evidence:
• Review of agency records indicates compliance. (To be reviewed) • Other__________________________________________________________________
Indicator 4.5 Internal quality review procedures are in place. Evidence:
• A description of quality and documentation review is maintained in client’s records to ensure adequate supervision. (To be reviewed)
• Monthly reports are submitted that address quality assurance at case management agencies.
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
• Quality assurance activities are reviewed at annual site visits by Program Associates. • Other__________________________________________________________________ Indicator 4.6 Provider consistency is maintained over time. Evidence: • Agencies assign all clients to a primary case manager and the AFC’s central registry
accurately reflects this case manager. • Charts document provider consistency or reasons for change within an agency or
between agencies. No interagency client transfer is made without consultation with the AIDS Foundation of Chicago or prior agreement between partner agencies. There is a procedure for notifying clients of a change in case manager. (To be reviewed)
• Other_____________________________________________________________________
Yes/No
Yes/No
Yes/No
Quality Standard #5: Case managers offer comprehensive services on-site or by referral that address client and family needs.
Indicator 5.1 All clients are assessed for individual and family needs at intake and every six months thereafter.
Evidence:
• Review of client file indicates compliance. • Other__________________________________________________________________
Indicator 5.2 Client service plan specific to client and family need is documented for each client and is signed by the client and case manager. Evidence:
• Review of client file indicates compliance. • Other__________________________________________________________________
Indicator 5.3 Client chart documents referrals made within the current six month assessment period.
Evidence:
� Review of client file indicates compliance. � Other__________________________________________________________________
Yes/No
Yes/No
Yes/No
Ryan White Case Management Survey Agency Response
QUALITY STANDARD 1: Services available are culturally sensitive and competent with regard to language, culture, spirituality, sexual orientation, age, gender, race, etc. Indicator 1.1 Outreach is targeted to specific communities of need in a manner that is consistent with community culture. Evidence:
• Client input in service delivery through participation in advisory board (Case Management Governance), and so on is documented.
• Promotional information is easily understood by all people and is oriented to target specific communities.
• Other:___________________________________________________________
Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Indicator 1.2 Services are conducted in a language/method that is sensitive to the communities served and case managers are aware of assisting clients in identifying issues that may be affected by race, primary language, sexual orientation, age, gender, disability, communities identified with, family needs and customs. Evidence:
• Intake formats provide opportunity for clients to discuss barriers to care specific to their culture and needs.
• Case managers are trained in addressing and assessing needs for specific communities. Onsite documentation is available.
• Other:________________________________________________________________
Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 1.3 Staff are competent at serving their target populations. Evidence:
• Resumes on file reflect previous experience with and education about diverse populations. • Case managers attend trainings that address diverse community issues. On site documentation is
available. Other:_________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
QUALITY STANDARD 2: Services are offered in such a way as to overcome barriers to access and utilization. Indicator 2.1 Services are accessible by all means of transportation. Evidence:
• Services are accessible by all means of transportation. • Alternate services sites or referral sources are maintained that are geographically sensitive to clients
needs. Demonstration is made for necessary services through memorandums of agreement or linkage agreements.
• Annual client survey indicates satisfaction with program site. Agency has demonstrated participation in AFC client satisfaction survey.
• Other_____________________________________________________________
Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 2.2 Supportive accommodations are made. Evidence:
• There is documentation that transportation resources are available to eligible clients to facilitate clients’ receipt of case management services.
• Agency provides home visits as needed and clinically indicated and appropriate documentation is maintained.
• Special transportation needs are assessed and made available to clients. Charts document assessments for transportation.
• Other_______________________________________________________________
Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 2.3 Services site is physically accessible to persons living with HIV. Evidence:
• ADA is complied with: accessible entrances with clear language, accommodations for people with visual or hearing impairments.
• Translation services are utilized when necessary and chart documentation supports client assessments.
• Other__________________________________________________________________
Indicator 2.3 (continued) Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 2.4 Services are offered in a timely fashion, both in terms of service hours and in terms of reasonable length of time between referral and initial contact. Evidence:
• Response time for new referral is appropriate for the level of care indicated at time of referral. • Frequency of ongoing contact is based on client level of need and need for care.
• Reassessments are done in a timely fashion and indicate any changes in client level of need for need for care.
• Procedures are in place to ensure clients have access to information regarding services in case of emergencies 24 hours a day.
Other_________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Quality Standard #3: Case managers and other agency staff maintain and uphold client rights and client confidentiality. Indicator 3.1 Staff and clients review agreement regarding client rights and responsibilities, and a signed receipt of the statement is in client file.
Evidence: • Review of client file indicates compliance. • Other__________________________________________________________________
Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 3.2 Staff and clients review agency policy regarding methods of chart access, and a signed receipt of the policy in client file.
Evidence:
• Review of client file indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 3.3 There is a signed release of information for every collateral or third-party contact in client file. Evidence:
• Review of client file indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 3.4 Clients will be informed at intake of eligibility criteria, grievance procedures, description of agency services, and the right to participate in agency client advisory board or client input forms, when applicable. Evidence:
• Review of client file indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 3.5 There is a forum for client input at the agency (i.e. focus groups, client advisory board, client surveys).
Evidence:
• Review of client file indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 3.6 Client records are kept in lockable file cabinets, and computer information is appropriately secured. Evidence:
• Facility tour indicates compliance. Other____________________________________________________________ Agency response: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Quality Standard #4: Services are professional, clinical and adhere to the standards set by the Northeastern Illinois HIV/AIDS Case Management Cooperative Governance. Indicator 4.1 Case managers are trained through the Cooperative orientation and receive certification upon completion.
Evidence:
• Documentation is on file at the AIDS Foundation.
• Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Indicator 4.2 Case managers are supported in professional and personal development to maintain service abilities. Evidence: • Case managers have adequate vacation, bereavement leave, and personal leave through agency
policies. • Case managers have regular supervision with attention to burnout as indicated through policies and
reviewed at annual site visits. • Case managers have annual in-services on self-care, physical and emotional. • Agency assesses case managers needs for ongoing education, including skill development and
informational needs to serve people with HIV. Documented by attendance records. • Training for case managers includes annual updates about basic HIV medical information, especially
targeting specific populations at risk, i.e., women with children, elderly, etc. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 4.3 There is documentation that a case manager has attended a minimum amount of ongoing training to provide case management services through the Cooperative for the previous year. Evidence:
• Review of staff training records indicates compliance. Other__________________________________________________________________
Indicator 4.3 (continued) Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 4.4 Job descriptions for case managers are on file. Evidence:
• Review of agency records indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 4.5 Internal quality review procedures are in place. Evidence: • A description of quality and documentation review is maintained in clients’ records to ensure
adequate supervision. • Monthly reports are submitted that address quality assurance at case management agencies. • Quality assurance activities are reviewed at annual site visits by Program Associates and
Coordinators. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 4.6 Provider consistency is maintained over time. Evidence: • Agencies assign all clients to a primary case manager and the AFC’s central registry accurately
reflects this case manager. • Charts document provider consistency or reasons for change within an agency or between agencies.
No interagency client transfer is made without consultation with the AIDS Foundation of Chicago or prior agreement between partner agencies. There is a procedure for notifying clients of a change in case manager.
Other_____________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Quality Standard #5: Case managers offer comprehensive services on-site or by referral that address client and family needs. Indicator 5.1 All clients are assessed for individual and family needs at intake and every six months thereafter.
Evidence:
• Review of client file indicates compliance. • Other__________________________________________________________________
Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 5.2 Client service plan specific to client and family need is documented for each client and is signed by the client and case manager. Evidence:
• Review of client file indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Indicator 5.3 Client chart documents referrals made within the current six month assessment period.
Evidence:
� Review of client file indicates compliance. Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Quality Standard #6: Services are part of the coordinated HIV Case Management Cooperative, including coordination with other service providers. Indicator 6.1 Effective communication is occurring within the agency and between partners. Evidence: • Review of client chart includes release of information documentation.
• When multiple services are available on site and are offered to clients, case staffings will occur and
will be documented in a formal manner. • Other__________________________________________________________________ Agency response: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
CASE MANAGEMENT RECORD REVIEW Use the following codes in documenting components in the case management service record:
“1/1” for present and required “0/1” for absent and required “0/0 or NA” for not applicable “N” for note
CRITERIA 1 2 3 4 5
Record ID# Documentation of HIV Status
Acuity score included
# Contacts (last 3 months)
Contact are consistent with acuity score
Intake date reasonable from screening date
SERVICE RECORD INCLUDES Completed intake/assessment forms-
● Page 1
● Page 2
________
________
________
________
________
Consent to enroll-signed & witnessed
Release of information-signed & witnessed
Rights and responsibilities- signed &
witnessed
Service plan is in file
Service plan is up to date
Documentation of client enrollment in
primary care
Monitoring and intervention activities are
included in progress notes(acuity, referrals,
notes)
Linkages made are documented
ECA is included in chart with all required
documentation.
Documentation in charts of other options
used before ECA.
Progress notes reflect the payment made for
client with ECA.
Progress notes are dated
Progress notes are signed
Change of status form (date)
Reassessment every six months
(documentation otherwise)
Supervisory notes in client record
Discharge plan
COMMENTS:
TOTAL SCORE
Definition of Terms for Chart Review
Documentation of HIV Status: acceptable documentation of HIV status includes HOPWA Health
Screening Form indicating HIV infection, positive viral load lab results with the patient’s name, SSA
disability certification naming HIV, ORS certification (residual capacity), written statement from a
primary care physician, HIV antibody test results that include client’s name.
Acuity score included: case intake forms that include the acuity score format must include the acuity
score at intake for all clients.
# Contacts (last 3 months): all contacts (face-to-face, telephone, and collateral) will be counted
Contacts are consistent with acuity score: contact will be compared to the guideline for contact
based on acuity score as per the Case Management Standard Operating Policies dated September 1999.
Intake date reasonable from screening date: date of initial intake will be compared to the date of
referral to ensure timeliness of contact or contact attempts on the part of the case manager as per the
Case Management Standard Operating Policies dated September 1999.
Completed intake/assessment forms (Page 1 and Page 2): presence and completeness of both forms
will be assessed.
Consent to enroll-signed & witnessed: Consent to Enroll in Central Registry must be present in all
client charts and signed by the client and witnessed by anyone (this may include but is not limited to
the case manager).
Release of information-signed & witnessed: releases of information must be present in all charts and
documented for any collateral contact made on behalf of the client. All referrals and collateral contacts
will be reviewed for the inclusion of a release of authorization allowing contact and information
sharing to occur.
Rights and responsibilities- signed & witnessed: all client charts must include a client rights and
responsibilities that includes a clear grievance procedure and is signed by the client and witnessed
anyone (this may include but is not limited to the case manager).
Service plan in file and up to date: all charts must have a service plan that is no older than six
months without appropriate documentation detailing the reason why a service plan has not been
updated in the last six months.
Documentation of client enrollment in primary care: acceptable documentation of current client
enrollment in primary care includes a note no greater than six months old documenting case manager
knowledge of the client’s primary care provider and status of kept appointments, lab values for client
that are no greater than six months old, copies of prescriptions that are no greater than six months old,
notes reflecting accompaniment to medical appointments or coordination of transportation to medical
appointments (specified in note as based on medical need).
Monitoring and intervention activities are included in progress notes (acuity, referrals, and
notes): client charts will be reviewed to ensure that client acuity scores, referrals and linkages made,
and case notes are consistent in attempting to address client needs. When there are differences,
documentation will be sought to explain this.
Linkages made are documented: all referrals made will be reviewed to ensure appropriate
documentation is kept for all referrals (in acuity, in case notes, in service plan, in transportation and
food voucher logs, etc.).
Documentation in charts of other options used before ECA: charts for clients who have accessed
the ECA program within the last three months will be reviewed to ensure that case managers have
attempted to use other resources before they access the Title I ECA Program. For further information
please refer to the ECA Guidelines implemented in January 2000.
Progress notes reflect the payment made for client with ECA: charts for clients who have accessed
the ECA program within the last three months will be reviewed to ensure that case managers have
documented that payment was mailed or delivered to the appropriate person as per the request for
reimbursement form submitted to the AIDFS Foundation of Chicago.
Progress notes are dated: all notes must be dated with their date of contact in a legible manner.
Progress notes are signed: all notes must be signed by the case managers with full name at the end of
each individual note or initialed after each note and include full signature at the bottom of each page of
notes.
Reassessment every six months (documentation otherwise): charts will be reviewed to ensure that
reassessments are done at minimum every six months (three months for Corrections and PACPI
clients). Documentation will be sought for charts with reviews at intervals greater than six months.
Supervisory notes in client record: all client charts will be reviewed for evidence of some
administrative review. Case notes of supervisory meetings or client file reviews are acceptable
examples of documentation that will be allowed.
Discharge plan: clients with case status change forms that indicate voluntary client case closure will
be reviewed to ensure that clients are given a discharge plan prior to case closure.
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT
COOPERATIVE 2005 SITE VISIT
Case Load Monitoring
1) At the current time, how many active cases does the agency have? RW _____ ORS _____ CORR _____
PACPI _____ CHHP _______ HOPWA/SPNS ______ Safe Start ______
How often and what is the format for evaluating caseloads?_________________________
_____________________________________________________________________________
_
3 ) Describe where your new case management clients are referred from, including an estimation of recent
referral demographics, and case assignment process.
Programmatic Administrative Procedures
1) Describe the agency’s grievance procedure, and demonstrate how the agency is prepared to respond or has
responded to client grievances in the past. Be prepared to submit a written grievance, either through chart
notes or formal incident reports.
2) Describe how your agency responded to any recommendations or deficiencies identified in last year’s site
visit report?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_________________________________________________________
3) The AIDS Foundation is in the process of creating templates for evaluating linkage to primary care. Please
share with us your linkage agreements with primary care agencies.
_____________________________________________________________________________
_____________________________________________________________________________
_______________________________________________
4) What technical assistance/support could AFC provide to you?
_____________________________________________________________________________
_____________________________________________________________________________
_______________________________________________
Page 1 of 8 Revised 09/06/07
CASE MANAGEMENT POLICY
Program Administration and Quality Management
Subject: SOP 18 – Client Satisfaction Surveys
Date: February 29, 2008 Page 1 of 8
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the collection of client
feedback on the quality of case management services.
POLICY: AFC will facilitate the distribution annual Client Satisfaction Surveys to all case-managed client
across the Cooperative to be completed voluntarily and confidentially.
PROCEDURE: The Illinois Department of Public Health (IDPH) and the Chicago Department of Public Health
(CDPH) require the completion of a client satisfaction survey annually. AFC, in conjunction
with its funders, develops and provides a tool for the collection of this quality management
feedback. These surveys are typically distributed in December and are requested back to AFC in
February or March. Surveys will be provided to subcontracted agencies based on the number of
open case-managed clients at each agency; case-managed agencies with Spanish-speaking clients
will be given surveys in Spanish as well. Agencies are responsible for distributing the surveys to
their clients. This may be done via mailings or face-to-face contact, with respect to client
confidentiality requests. AFC will provide agencies with self-addressed envelopes to return the
surveys; completed surveys must be sealed to maintain client anonymity. It is expected that an
agency will have a return rate of at least 25% of the surveys distributed.
Results of Satisfaction Surveys will be collected and analyzed by AFC and an outside contracted
evaluation unit. These results will be made available to AFC funders and stakeholders in
aggregate and will guide future direction of services and quality management review. Results
will also be made available to individual agencies both in aggregate and specific to the agency,
as return rates allow. Individual agencies are encouraged to review the feedback internally and
make necessary adjustments and changes to services as appropriate.
AFC’s Satisfaction Surveys can serve as the individual agency’s required satisfaction surveys but
may also be augmented by internal evaluative tools if desired. Agencies must provide AFC with
results of other satisfaction surveys done that target case- managed clients. These results can be
reported via narrative monthly reports.
Subcontracted agencies will be required to report on how results from this or other agency-
specific satisfaction surveys are used to improve ongoing services. This will be addressed at the
agency’s site visit (SOP 17).
FORMS: Client Satisfaction Survey
Page 1 of 8 Revised 09/06/07
2007 Illinois Ryan White Part B Client Satisfaction Survey
In order to provide the best services possible, please comment about your experiences with the following
services. Please rate the items listed below on a scale of 1 to 5, with 1 being “Below Average” and 5 being
“Above Average.” Circle the appropriate response only in the sections that apply to the services you have
received in the last 12 months. Please do not comment on the services you have not received.
Your name will not be attached to this form and your answers are completely anonymous. The services you
receive will not be affected by any response, positive or negative.
Consortia Region (Check one):
Champaign Collar Cook Effingham Jackson
Peoria Rock Island Sangamon St. Clair Winnebago
Case Management Services
1. I most recently received case management services from the following agency (please print clearly):
I have not used this service (please skip to the next service)
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Quality of Service (professionalism) 5 4 3 2 1
3. Ease of Appointment (accessibility) 5 4 3 2 1
4. Confidentiality/privacy 5 4 3 2 1
5. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
6. Overall satisfaction 5 4 3 2 1
Dental Services
1. I most recently received dental services from the following provider:
I have not used this service (please skip to the next service)
Above
Average (5) 4 Average (3) 2
Below
Average (1)
1. Quality of Service (professionalism) 5 4 3 2 1
2. Ease of Appointment (accessibility) 5 4 3 2 1
3. Confidentiality/privacy 5 4 3 2 1
4. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
5. Overall satisfaction 5 4 3 2 1
Page 2 of 8 Revised 09/06/07
Food Bank/Home-Delivered Meals Services
1. I received the following food bank/home-delivered meal services in the previous 12 months (check all that
apply):
Food Vouchers Food Baskets
Food Pantry Home-Delivered Meals
Nutritional supplements (such as vitamins, Boost™, or Ensure™)
I have not used this service (please skip to the next service)
Housing (Short-term rental assistance or emergency/temporary housing assistance)
1. I received the following types of housing assistance (check all that apply):
Rental Assistance Emergency Housing Mortgage Assistance
I have not used this service (please skip to the next service)
Legal Services (powers of attorney, do-not-resuscitate orders, and access to eligible benefits)
1. I received legal services from the following provider:
I have not used this service (please skip to the next service)
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Quality of Service 5 4 3 2 1
3. Ease of Appointment (accessibility) 5 4 3 2 1
4. Confidentiality/privacy 5 4 3 2 1
5. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
6. Overall satisfaction 5 4 3 2 1
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Confidentiality/privacy 5 4 3 2 1
3. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
4. Helped maintain my independence 5 4 3 2 1
5. Overall satisfaction 5 4 3 2 1
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Quality of Service 5 4 3 2 1
3. Ease of Appointment (accessibility) 5 4 3 2 1
4. Confidentiality/privacy 5 4 3 2 1
5. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
6. Overall satisfaction 5 4 3 2 1
Page 3 of 8 Revised 09/06/07
Mental Health Services
1. I received mental health services from the following provider:
I have not used this service (please skip to the next service)
Primary Health Care Services
1. I received primary health care services from the following provider:
I have not used this service (please skip to the next service)
Rehabilitation Services (physical and occupational therapy, speech pathology, or low-vision
training)
1. I received rehabilitation services from the following provider:
I have not used this service (please skip to the next service)
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Quality of Service 5 4 3 2 1
3. Ease of Appointment (accessibility) 5 4 3 2 1
4. Confidentiality/privacy 5 4 3 2 1
5. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
6. Overall satisfaction 5 4 3 2 1
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Quality of Service 5 4 3 2 1
3. Ease of Appointment (accessibility) 5 4 3 2 1
4. Confidentiality/privacy 5 4 3 2 1
5. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
6. Overall satisfaction 5 4 3 2 1
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Quality of Service 5 4 3 2 1
3. Ease of Appointment (accessibility) 5 4 3 2 1
4. Confidentiality/privacy 5 4 3 2 1
5. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
6. Overall satisfaction 5 4 3 2 1
Page 4 of 8 Revised 09/06/07
Substance Use Counseling Services
1. I received substance use counseling services from the following provider:
I have not used this service (please skip to the next service)
Support Groups
1. I received support group services from the following provider:
I have not used this service (please skip to the next service)
Transportation Services (bus passes, taxi, hired driver, gas vouchers, or mileage
reimbursement)
1. I have received the following types of transportation services in the previous 12 months (check all that
apply):
Bus passes Metro passes Gas vouchers
Mileage reimbursement Taxi services Hired driver services
I have not used this service (please skip to the next service)
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Quality of Service 5 4 3 2 1
3. Ease of Appointment (accessibility) 5 4 3 2 1
4. Confidentiality/privacy 5 4 3 2 1
5. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
6. Overall satisfaction 5 4 3 2 1
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Quality of Service 5 4 3 2 1
3. Confidentiality/privacy 5 4 3 2 1
4. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
5. Overall satisfaction 5 4 3 2 1
6. Helped maintain my independence 5 4 3 2 1
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Confidentiality/privacy 5 4 3 2 1
3. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
4. Helped maintain my independence 5 4 3 2 1
5. Overall satisfaction 5 4 3 2 1
Page 5 of 8 Revised 09/06/07
Utility Assistance
1. I have received utility assistance service in the previous 12 months:
Yes, I have received utility assistance in the previous 12 months
No, I have not used this service (please skip to the final section)
Prevention Services
Please tell us about yourself (demographic information) 1. Are you: (check only one)
Male
Female
Transgender (male to female)
Transgender (female to male)
2. What is your age?
17 and younger
18-24
25-44
45-64
65 and older
3. What race/ethnicity best describes you? (check all
that apply)
White
Black or African American
Hispanic or Latino/a
Asian
Native Hawaiian or Pacific Islander
American Indian or Alaskan Native
Unknown
4. What is the zip code where you live?
5. What behavioral/risk factors did you have at the time
you were diagnosed with HIV or AIDS?
Sex with male
Sex with female
Injection drug use
Received blood/blood products
Mother is/was HIV+
Sex with a person who injected drugs
Other ________________________
6. What behavioral/risk factors do you currently have?
(check all that apply)
Sex with male
Sex with female
Injection drug use
Sex with a person who injected drugs
Other ________________________
7. Approximately how many contacts (both phone and
face-to-face) have you had with your case manager
in the past 12 months?
None 1-2
3-4 5-6
7-12 13 or more
Above
Average (5) 4 Average (3) 2
Below
Average (1)
2. Quality of Service 5 4 3 2 1
3. Helped me access or stay in medical
treatment for my HIV disease 5 4 3 2 1
4. Helped maintain my independence
5. Overall satisfaction 5 4 3 2 1
1. It has been easy for me to access free condoms. Does Not Apply Yes No
2. I know where I can receive free counseling to help me change my risky
sexual or drug using behavior. Does Not Apply Yes No
3. I know where I can refer a friend or sexual partner for free, anonymous
HIV testing. Does Not Apply Yes No
4. I am able to talk to my case manager about prevention or risk reduction
behaviors and services. Does Not Apply Yes No
2 Revised 11/06/07
Please tell us about yourself (demographic information) Continued
8. In your opinion, did you have too few, just the right
number, or too many contacts with your case
manager in the past 12 months?
Too few contacts
Just the right number of contacts
Too many contacts
9. Have you had either a CD4 (T-cell) or viral load test
done in the past 12 months?
Yes No Unknown
10. Do you currently have any kind of health care
coverage, including health insurance?
Yes, I have (please check all that you currently
have)
Medicaid
Medicare
Veteran’s Administration
Private insurance
Other insurance __________
Some insurance, not sure what type
No
Unknown
11. Was there a time in the past 12 months that you did
not have any health insurance coverage?
Yes No Unknown
12. Do you have access to a computer with Internet
access?
Yes No Unknown
13. How would you prefer to complete this survey in the
future? (please check one)
Paper copy to mail in
Complete it on the Internet
Either mail or online, no preference
Unknown
COMMENTS
2 Revised 11/06/07
14. What other rental or utility assistance programs have you applied for or has your case
manager discussed with you (such as LIHEAP, Section 8, etc.)? What assistance have you
received?
15. What one thing would most improve the quality of your case management services?
16. Please use this space to comment on any needs not being met or any of the services you have
received.
Thank you for completing this client satisfaction survey.
Your responses are important in improving our program.
CASE MANAGEMENT POLICY
Case Management Services
Subject: SOP 19A - CTA and PACE Fare Cards and METRA passes
Date: July 31, 2007 Revised: February 29, 2008 Page 1 of 5
PURPOSE: The AIDS Foundation of Chicago (AFC) has developed the following policies and
procedures to assist case management agencies in providing transportation to HIV-
infected persons who are receiving healthcare services through the Northeastern Illinois
HIV/AIDS Case Management Cooperative. To enable the Cooperative to provide
transportation services for as many clients as possible, agencies and case managers must
adhere to these policies and procedures. Failure to follow these policies and procedures
will result in the loss of access to transportation services for the agency’s clients.
POLICY: These services are designed to provide subsidized transportation for case managed clients
to healthcare service appointments only. These services are defined by the Health
Resource Service Administration (HRSA) as ambulatory outpatient primary care
(doctors’ visits, non-HIV medical consults, lab work, and specialty care appointments),
substance abuse services (services provided under the care of a physician, or other
qualified professional in an outpatient setting), mental health (psychological or
psychiatric services rendered by licensed/qualified staff but does not include peer led
support groups), oral health care (diagnostic or preventative oral health visits by qualified
professional), and medical case management.
These services are limited and should be used strategically by case managers to address
transportation needs while clients are gaining access to ongoing subsidized transportation
via the Illinois Department of Public Aid (IDPA), the RTA/CTA special user passes and
services, and various local community transportation services.
To ensure that transportation services are being used in an effective and efficient manner,
agencies must follow these policies and procedures and to report client level utilization.
Furthermore, agencies should consider designating a lead person to be responsible for
coordinating transportation services and encourage case managers to become familiar
with the variety of transportation options that clients and families can use.
PROCEDURE:
Eligibility
A client must meet all of the following eligibility criteria in order to be eligible for CTA
and PACE fare cards and METRA passes: • The client must be enrolled in the AFC central registry and be receiving any level
• of case management services;
• The client must cooperate with his or her case manager and apply for and use all
appropriate available transportation options (e.g., IDPA Medicar, RTA special
user’s pass, RTA Seniors Ride Free Program);
• Client’s income is at or below 50% of the area median income;
• Client affirms that he/she has no other transportation resources available to them;
and
• Client affirms that he/she does not have an RTA reduced fare card or Paratransit
service and is not eligible. If the client has an RTA reduced fare card and meets
the criteria above, they are eligible to receive reduced fare CTA fare cards.
Responsibilities of Client
1. The client must accurately answer the Transportation Assessment on the Intake
Assessment (SOP 3) or Reassessment (SOP 8) prior to accessing transportation
through AFC.
2. The client must cooperate with his or her case manager and apply for and use all
appropriate transportation (e.g., IDPA Medicar, RTA special user’s pass). If the
client has difficulty accessing the Medicar, they must inform their case manager and
complete the Medicar Complaint Form. If the client has two or more documented
Medicar complaints within a six-month period, they will be eligible to access AFC-
funded transportation services.
Responsibilities of Case Management Cooperative Agency
1. The case manager will assess the client’s long and short term transportation needs
and transportation resources utilizing AFC’s transportation assessment on page four
of the Intake (SOP 3) or Reassessment (SOP 8). The case manager and client will
develop a transportation plan to meet the client’s long-term transportation needs.
The plan will be documented in the client’s record in the service plan and progress
notes. Case managers will reassess client transportation needs on an ongoing basis
(at least every six months).
2. As part of the assessment and planning process, the case manager will discuss with
the client other transportation programs/options that are available and help the client
apply for other resources. Other sources of transportation that could be used
include:
• Personal car
• Family member or friend
• Volunteers (in agencies with volunteer staff)
• CTA Reduced Fare Card
• RTA’s special user’s pass or RTA Seniors Ride Free Program
• Paratransit
• Local government programs for transportation services for the disabled
• Illinois Department of Public Aid
• Shuttle vans provided by many of the medical/treatment facilities
3. Case managers must document in the client file when the AFC-funded
transportation service is used and a rationale for why this was the preferred mode
of transportation. If the client has an RTA reduced fare card, the agency can give
the client a reduced fare CTA card.
4. Each agency will have a contact person whose responsibilities include enforcing
transportation guidelines and procedures, monitoring case manager’s use of
passes, and submitting documentation of and passes to AFC. The usage of fare
cards and METRA passes are to be entered into the client-level database.
5. The agency must follow up with the client when there are problems or misuse of
the AFC-funded transportation service. Repeated client misuse of the service may
lead to loss of transportation privileges.
6. The agency must notify AFC of any changes in personnel with access to
transportation privileges.
7. The agency will be financially responsible for any transportation rides that are not
logged. Frequent or continuous violations of these guidelines by case managers
or agencies may result in the suspension of access to transportation services by
the agencies clients.
8. Agencies are able to request CTA and PACE fare cards and METRA at a
maximum of once every three months. Case management agency staff must
contact the assigned AFC Program Staff member to make the request. The
amount of money to be used for fare cards is based both on the number of full-
time equivalent case management positions that an agency has and the amount of
funding available for this resource.
9. To request METRA passes, the case management agency staff must also supply
AFC with the METRA stations to and from which the client will be traveling and
the number of rides they are requesting. A check will be cut for that amount.
10. Agencies are responsible for sending a copy of the receipts from CTA, PACE and
METRA to AFC.
Responsibilities of the AIDS Foundation of Chicago (AFC)
1. AFC staff will maintain client central registries for both case management and
transportation services.
2. AFC will provide timely responses to any special request for transportation
approval.
3. AFC will notify agencies/case managers of any problems related to use of the
transportation services in a timely manner.
4. AFC will notify agencies if transportation funds for transportation services are
restricted or unavailable.
5. AFC will provide agencies with CTA fare cards and METRA train passes as long as
funds are available and the agency has no other source for this resource.
6. AFC will notify the agency of any unauthorized ride or rides that violate the
established guidelines. Any unauthorized rides will not be paid for by AFC and are
the responsibility of the agency.
FORMS:
Medicar Complaint Form
AIDS Foundation
O F C H I C A G O
411 South Wells Street Tel (312) 922-2322 Suite 300 Fax (312) 922-2916 Chicago, IL 60607 TDD (312) 922-2917
MEDICAR COMPLAINTS
Date: ____________________________________
Agency: ____________________________________
Staff Member: ____________________________________
Date of Incident: ____________________________________
Date/Time of Car Order: ____________________________________
Car Company:
Car Number: ____________________________________
Pick-Up Address: ____________________________________
Destination: ____________________________________
Other ____ No Show ____ Round Trip ____ One Way
Narrative (please write legibly):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
10/27/06
CASE MANAGEMENT POLICY
Case Management Services
Subject: SOP 19B - Gas Cards
Date: February 29, 2008 Page 1 of 5
PURPOSE: The AIDS Foundation of Chicago (AFC) has developed the following policies and
procedures to assist case management agencies in providing transportation to HIV-
infected persons who are receiving healthcare services through the Northeastern Illinois
HIV/AIDS Case Management Cooperative. To enable the Cooperative to provide
transportation services for as many clients as possible, agencies and case managers must
adhere to these policies and procedures. Failure to follow these policies and procedures
will result in the loss of access to transportation services for the agency’s clients.
POLICY: These services are designed to provide subsidized transportation for case managed clients
to healthcare service appointments only. These services are defined by the Health
Resource Service Administration (HRSA) as ambulatory outpatient primary care
(doctors’ visits, non-HIV medical consults, lab work, and specialty care appointments),
substance abuse services (services provided under the care of a physician, or other
qualified professional in an outpatient setting), mental health (psychological or
psychiatric services rendered by licensed/qualified staff but does not include peer led
support groups), oral health care (diagnostic or preventative oral health visits by qualified
professional), and medical case management.
These services are limited and should be used strategically by case managers to address
transportation needs while clients are gaining access to ongoing subsidized transportation
via the Illinois Department of Public Aid (IDPA), the RTA/CTA special user passes and
services, and various local community transportation services.
To ensure that transportation services are being used in an effective and efficient manner,
agencies must follow these policies and procedures and to report client level utilization.
Furthermore, agencies should consider designating a lead person to be responsible for
coordinating transportation services and encourage case managers to become familiar
with the variety of transportation options that clients and families can use.
Gas cards are to be distributed to clients living in Suburban Cook and Collar
Counties only. This service is only available to clients who do not have access to
reasonable public transportation options.
PROCEDURE:
Eligibility
In order to be eligible to receive gas cards, a client must meet all of the following criteria:
• The client must be enrolled in the AFC central registry and be receiving any level
of case management services; • The client must cooperate with his or her case manager and apply for and use all
appropriate available transportation (e.g., IDPA Medicar);
• Client’s income is at or below 50% of the area median income to be eligible;
• Client affirms that he/she has access to an automobile, but has no other
transportation resources available to them;
• Client resides in suburban Cook County or in one of the Collar Counties (Will,
Grundy, Kane, DuPage, Kane, McHenry or Lake); and
• Client affirms that public transportation does not serve point of origin or
destination.
Responsibilities of Client
1. The client must accurately answer the Transportation Assessment on the Intake
Assessment (SOP 3) or Reassessment (SOP 8) prior to accessing transportation
through AFC.
2. The client must cooperate with his or her case manager and apply for and use all
appropriate transportation (e.g., IDPA Medicar). If the client has difficulty
accessing the Medicar, they must inform their case manager and complete the
Medicar Complaint Form. If the client has two or more documented Medicar
complaints within a six-month period, they will be eligible to access AFC-funded
transportation services.
3. Clients requesting gas cards must provide the case manager with accurate
information on the type of appointment, pick-up address, destination address, and
origin address. The client must agree to make no unauthorized stops during the
course of the ride
4. A client may receive one $10.00 gas card if the round trip is 50 miles or less. If the
trip is between 51 and100 miles, the client may receive two $10.00 gas cards. Any
trips in excess of 100 miles round trip require prior approval of AFC Program Staff.
Responsibilities of Case Management Cooperative Agency
1. The case manager will assess the client’s long and short term transportation needs
and transportation resources utilizing AFC’s transportation assessment on page four
of the Intake (SOP 3) or Reassessment (SOP 8). The case manager and client will
develop a transportation plan to meet the client’s long term transportation needs.
The plan will be documented in the client’s record in the service plan and progress
notes. Case managers will reassess client transportation needs on an ongoing basis
(at least every six months).
2. Gas cards will be distributed to agencies serving suburban Cook and Collar County
clients based upon the amount of funds available. Clients requesting gas cards will
inform the case manager of the address of origin and destination to be traveled.
Based on the addresses provided, case managers will calculate the number of gas
cards needed for a round trip. The cards will be available in denominations of
$10.00. A client may receive one $10.00 gas card if the round trip is 50 miles or
less. If the trip is between 51 and100 miles, the client may receive two $10.00 gas
cards. Any trips in excess of 100 miles round trip require prior approval of AFC
Program Staff.
3. As part of the assessment and planning process, the case manager will discuss with
the client other transportation programs/options that are available and help the client
apply for other resources. Other sources of transportation that could be used
include:
• Personal car
• Family member or friend
• Volunteers (in agencies with volunteer staff)
• Paratransit
• Local government programs for transportation services for the disabled
• Illinois Department of Public Aid
• Shuttle vans provided by many of the medical/treatment facilities
4. Case managers must document in the client file when the AFC-funded
transportation service is used and a rationale for why this was the preferred mode
of transportation.
5. Each agency will have a contact person, whose responsibilities include enforcing
transportation guidelines and procedures, monitoring case manager’s use of gas
cards, and submitting documentation of usage to AFC. The usage of gas cards
must be entered into the client-level database.
6. The agency must follow up with the client when there are problems or misuse of
the AFC-funded transportation service. Repeated client misuse of the service may
lead to loss of transportation privileges.
7. The agency must notify AFC of any changes in personnel with access to
transportation privileges.
8. The agency will be financially responsible for any gas cards that are not logged.
Frequent or continuous violations of these guidelines by case managers or agency
may result in the suspension of access to transportation services by the agencies.
Responsibilities of the AIDS Foundation of Chicago (AFC)
1. AFC staff will maintain client central registries for both case management and
transportation services.
2. AFC will provide timely responses to any special request for transportation
approval.
3. AFC will notify agencies/case managers of any problems related to use of the
transportation services in a timely manner.
4. AFC will notify agencies if transportation funds for transportation services are
restricted or unavailable.
5. AFC will provide agencies with gas cards as long as funds are available and the
agency has no other source for this resource.
6. AFC will notify the agency of any unauthorized ride or rides that violate the
established guidelines. Any unauthorized rides will not be paid for by AFC and are
the responsibility of the agency.
FORMS:
Medicar Complaint Form
AIDS Foundation
O F C H I C A G O
411 South Wells Street Tel (312) 922-2322 Suite 300 Fax (312) 922-2916 Chicago, IL 60607 TDD (312) 922-2917
MEDICAR COMPLAINTS
Date: ____________________________________
Agency: ____________________________________
Staff Member: ____________________________________
Date of Incident: ____________________________________
Date/Time of Car Order: ____________________________________
Car Company:
Car Number: ____________________________________
Pick-Up Address: ____________________________________
Destination: ____________________________________
Other ____ No Show ____ Round Trip ____ One Way
Narrative (please write legibly):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
10/27/06
CASE MANAGEMENT POLICY
Case Management Services
Subject: SOP 19C - Taxi Service
Date: January 1, 2007 Revised: February 29, 2008 Page 1 of 7
PURPOSE: The AIDS Foundation of Chicago (AFC) has developed the following policies and
procedures to assist case management agencies in providing transportation to HIV-
infected persons who are receiving healthcare services through the Northeastern Illinois
HIV/AIDS Case Management Cooperative. To enable the Cooperative to provide
transportation services for as many clients as possible, agencies and case managers must
adhere to these policies and procedures. Failure to follow these policies and procedures
will result in the loss of access to transportation services for the agency’s clients.
POLICY: These services are designed to provide subsidized transportation for case managed clients
to healthcare service appointments only. These services are defined by the Health
Resource Service Administration (HRSA) as ambulatory outpatient primary care
(doctors’ visits, non-HIV medical consults, lab work, and specialty care appointments),
substance abuse services (services provided under the care of a physician, or other
qualified professional in an outpatient setting), mental health (psychological or
psychiatric services rendered by licensed/qualified staff but does not include peer led
support groups), oral health care (diagnostic or preventative oral health visits by qualified
professional), and medical case management.
These services are limited and should be used strategically by case managers to address
transportation needs while clients are gaining access to ongoing subsidized transportation
via the Illinois Department of Public Aid (IDPA), the RTA/CTA special user passes and
services, and various local community transportation services.
To ensure that transportation services are being used in an effective and efficient manner,
agencies must follow these policies and procedures and to report client level utilization.
Furthermore, agencies should consider designating a lead person to be responsible for
coordinating transportation services and encourage case managers to become familiar
with the variety of transportation options that clients and families can use.
Taxicabs are available to eligible clients only after all other options have been explored
and determined not viable to meet the client’s needs.
PROCEDURE:
Eligibility
In order to be eligible for taxi service, a client must meet all of the following criteria:
• The client must be enrolled in the AFC central registry and be receiving any level
of case management services;
• The client must cooperate with his or her case manager and apply for and use all
• appropriate available transportation (e.g., IDPA Medicar, RTA special user’s
pass, RTA Seniors Ride Free Program);
• Client’s income is at or below 50% of the area median income to be eligible;
• Client affirms that he/she has no other transportation resources available to them;
and
• Client affirms that he/she does not have an RTA reduced fare card or Paratransit
service and is not eligible.
In addition to meeting all of the above criteria, in order to be eligible for taxi service a
client must also meet at least one of the following criteria:
• Client has demonstrated difficulty ambulating (i.e. cannot climb stairs, cannot
walk more than 20 feet);
• Client has a documented physical disability that impedes safe access to public
transportation;
• Client affirms that public transportation does not serve point of origin or
destination;
• Client affirms that he/she is traveling with more than two infants or toddlers;
and/or
• Client has filed two documented complaints with AFC regarding Medicar services
within the last six months.
Responsibilities of Client
1. The client must accurately answer the Transportation Assessment on the Intake
Assessment (SOP 3) or Reassessment (SOP 8) prior to accessing transportation
through AFC.
2. The client must cooperate with his or her case manager and apply for and use all
appropriate transportation (e.g., IDPA Medicar, RTA special user’s pass). If the
client has difficulty accessing the Medicar, they must inform their case manager and
complete the Medicar Complaint Form. If the client has two or more documented
Medicar complaints within a six-month period, they will be eligible for services.
3. When accessing taxicab service, the client must provide the case manager with
accurate information on the type of appointment, pick-up address, destination
address, and time taxicab service is needed. The client must also be ready to leave
at the designated time for which the taxicab is scheduled. The client must agree to
make no unauthorized stops during the course of the ride.
4. Clients in need of round-trip service can arrange for a single cab to transport them
both ways if the scheduled wait time is less than ten minutes. If the wait time is
expected to be longer than ten minutes, two separate taxicab orders must be
completed and each logged as two separate trips.
Responsibilities of Case Management Cooperative Agency
1. The case manager will assess the client’s long and short term transportation
needs and transportation resources utilizing AFC’s transportation assessment on
page four of the Intake (SOP 3) or Reassessment (SOP 8). The case manager and
client will develop a transportation plan to meet the client’s long term
transportation needs. The plan will be documented in the client’s record in the
service plan and progress notes. Case managers will reassess client transportation
needs on an ongoing basis (at least every six months).
2. As part of the assessment and planning process, the case manager will discuss
with the client other transportation programs/options that are available and help
the client apply for other resources. Other sources of transportation that could be
used include:
• Personal car
• Family member or friend
• Volunteers (in agencies with volunteer staff)
• CTA Reduced Fare Card
• RTA’s special user’s pass, RTA Seniors Ride Free Program
• Paratransit
• Local government programs for transportation services for the disabled
• Illinois Department of Public Aid
• Shuttle vans provided by many of the medical/treatment facilities
3. Case managers must document in the client file when the AFC-funded
transportation service is used and a rationale for why this was the preferred mode
of transportation.
4. Each agency will have a contact person, whose responsibilities include enforcing
transportation guidelines and procedures, monitoring case manager’s use of
taxicabs, and submitting documentation of logged rides to AFC. The taxicab log
must be accurate and must be submitted to AFC as the cab rides are called in.
The cab log will include the core service accessed (see page one for allowable
services) and the specific qualifying criteria for taxi eligibility.
5. The agency must follow up with the client when there are problems or misuse of
the AFC-funded transportation service. Repeated client misuse of the service may
lead to loss of taxicab privileges.
6. The agency must notify AFC of any changes in personnel with access to
transportation privileges.
7. The agency/case manager will keep all taxicab service personal identification
numbers confidential and will protect them from client access. Under no
circumstances shall a case manager disclose their pin number to a client.
8. The agency will be financially responsible for any taxi rides that are not logged.
Frequent or continuous violations of these guidelines by case managers or
agencies may result in the suspension of access to transportation services by the
agencies clients.
9. Any unusual incidents must be documented on a Taxicab Complaint Form and
submitted to the AFC Program Staff for follow-up/ resolution.
Responsibilities of the AIDS Foundation of Chicago (AFC)
1. AFC staff will maintain client central registries for both case management and
transportation services. AFC staff will provide the taxicab vendors with current
lists of all personnel authorized to order taxicabs.
2. AFC staff will assign a personal identification number to each person authorized
to order taxicabs.
3. AFC will provide timely responses to any special request for transportation
approval.
4. AFC will notify agencies/case managers of any problems related to use of the
transportation services in a timely manner.
5. AFC will notify agencies if transportation funds for transportation services are
restricted or unavailable.
6. AFC will provide agencies with CTA fare cards, gas cards and METRA train
passes as long as funds are available and the agency has no other source for this
resource.
7. AFC will reconcile the agencies transportation logs with the billings submitted by
the taxicab companies.
8. AFC will notify the agency of any unauthorized ride or rides that violate the
established guidelines. Any unauthorized rides will not be paid for by AFC and
are the responsibility of the agency.
FORMS: Taxicab Complaint Form
Medicar Complaint Form
Taxi Log
AIDS Foundation
O F C H I C A G O
411 South Wells Street Tel (312) 922-2322 Suite 300 Fax (312) 922-2916 Chicago, IL 60607 TDD (312) 922-2917
TAXICAB COMPLAINTS
Date: ____________________________________
Agency: ____________________________________
Staff Member: ____________________________________
Date of Incident: ____________________________________
Date/Time of Cab Order: ____________________________________
Cab Company: ____________________________________
Dispatcher’s Name (if known): ____________________________________
Cab Number: ____________________________________
Pick-Up Address: ____________________________________
Destination: ____________________________________
____ No Show ____ Round Trip ____ One Way
Narrative:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
revised 10/25/05
AIDS Foundation
O F C H I C A G O
411 South Wells Street Tel (312) 922-2322 Suite 300 Fax (312) 922-2916 Chicago, IL 60607 TDD (312) 922-2917
MEDICAR COMPLAINTS
Date: ____________________________________
Agency: ____________________________________
Staff Member: ____________________________________
Date of Incident: ____________________________________
Date/Time of Car Order: ____________________________________
Car Company:
Car Number: ____________________________________
Pick-Up Address: ____________________________________
Destination: ____________________________________
Other ____ No Show ____ Round Trip ____ One Way
Narrative (please write legibly):
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________ 10/27/06
TAXI LOG AGENCY NAME
CLIENT FIRST & LAST NAME
DATE TIME RIDE ORIGIN DESTINATION AUTHORIZING
CASE MANAGER
CORE SERVICE
ACCESSED
ELIGIBILITY
CRITERIA
CAB COMPANY
1
2
3
4
CLIENT FIRST & LAST NAME
DATE TIME RIDE ORIGIN DESTINATION AUTHORIZING
CASE MANAGER
CORE SERVICE
ACCESSED
ELIGIBILITY
CRITERIA
CAB COMPANY
1
2
3
4
Core Services Key: CM= Medical Case Mgt. Eligibility Criteria Key: A= Client cannot climb stairs, cannot
HV= HIV Primary Care walk more than 20 feet)
PC= non-HIV Primary Care B= Client can not safely access public transportation.
MH= Mental Health Services C= Public transportation does not serve point of
SA= Substance Abuse Services origin or destination.
DT= Oral Health Services D= Client is traveling with more than two infants or
toddlers.
Revised 6/22/07
CASE MANAGEMENT POLICY
Case Management Services
Subject: SOP 19D- Van Service
Date: February 29, 2008 Page 1 of 4
PURPOSE: The AIDS Foundation of Chicago (AFC) has developed the following policies and
procedures to assist case management agencies in providing transportation to HIV-
infected persons who are receiving healthcare services through the Northeastern Illinois
HIV/AIDS Case Management Cooperative. To enable the Cooperative to provide
transportation services for as many clients as possible, agencies and case managers must
adhere to these policies and procedures. Failure to follow these policies and procedures
will result in the loss of access to transportation services for the agency’s clients.
POLICY: These services are designed to provide subsidized transportation for case managed clients
to healthcare service appointments only. These services are defined by the Health
Resource Service Administration (HRSA) as ambulatory outpatient primary care
(doctors’ visits, non-HIV medical consults, lab work, and specialty care appointments),
substance abuse services (services provided under the care of a physician, or other
qualified professional in an outpatient setting), mental health (psychological or
psychiatric services rendered by licensed/qualified staff but does not include peer led
support groups), oral health care (diagnostic or preventative oral health visits by qualified
professional), and medical case management.
These services are limited and should be used strategically by case managers to address
transportation needs while clients are gaining access to ongoing subsidized transportation
via the Illinois Department of Public Aid (IDPA), the RTA/CTA special user passes and
services, and various local community transportation services.
To ensure that transportation services are being used in an effective and efficient manner,
agencies must follow these policies and procedures and to report client level utilization.
Furthermore, agencies should consider designating a lead person to be responsible for
coordinating transportation services and encourage case managers to become familiar
with the variety of transportation options that clients and families can use.
Van services are to available to clients living in Suburban Cook and Collar Counties
only. This service is only available to clients who do not have access to reasonable public
transportation options. Each individual van service agency has its availability restrictions
and its own geographic area within which clients may be picked up and dropped off.
PROCEDURES:
Eligibility
In order to be eligible for van service, a client must meet all of the following criteria:
• The client must be enrolled in the AFC central registry and be receiving any level
of case management services;
• The client must cooperate with his or her case manager and apply for and use all
appropriate available transportation (e.g., IDPA Medicar, RTA special user’s
pass, RTA Seniors Ride Free Program);
• Client’s income is at or below 50% of the area median income to be eligible;
• Client affirms that he/she has no other transportation resources available to them;
and
• Client affirms that he/she does not have an RTA reduced fare card or Paratransit
service and is not eligible.
Responsibilities of Client
1. The client must accurately answer the Transportation Assessment on the Intake
Assessment (SOP 3) or Reassessment (SOP 8) prior to accessing transportation
through AFC.
2. The client must cooperate with his or her case manager and apply for and use all
appropriate transportation (e.g., IDPA Medicar, RTA special user’s pass). .
3. When accessing van service, the client must provide the case manager with accurate
information on the type of appointment, pick-up address, destination address, and
time taxicab service is needed. The client must also be ready to leave at the
designated time for which the van is scheduled. The client must agree to make no
unauthorized stops during the course of the ride.
4. The client must abide by the individual provider agency’s Rights and
Responsibilities.
Responsibilities of Case Management Cooperative Agency
1. The case manager will assess the client’s long and short term transportation
needs and transportation resources utilizing AFC’s transportation assessment tool.
The case manager and client will develop a transportation plan to meet the
client’s needs. The plan will be documented in the client’s record in the service
plan and progress notes. Case managers will reassess client transportation needs
on an ongoing basis (at least every six months).
2. As part of the assessment and planning process, the case manager will discuss
with the client other transportation programs/options that are available and help
the client apply for other resources. Other sources of transportation that could be
used include:
• Personal car
• Family member or friend
• Volunteers (in agencies with volunteer staff)
• CTA Reduced Fare Card
• RTA’s special user’s pass, RTA Seniors Ride Free Program
• Paratransit
• Local government programs for transportation services for the disabled
• Illinois Department of Public Aid
• Shuttle vans provided by many of the medical/treatment facilities
3. Case managers must document in the client file when the AFC-funded
transportation service is used and a rationale for why this was the preferred mode
of transportation.
4. Each agency will have a contact person, whose responsibilities include enforcing
transportation guidelines and procedures, monitoring case manager’s use of
transportation, and submitting documentation of logged rides to AFC.
5. The agency must follow up with the client when there are problems or misuse of
the AFC-funded transportation service. Repeated client misuse of the service may
lead to loss of transportation privileges.
6. The agency must notify AFC of any changes in personnel with access to
transportation privileges.
7. The agency will be financially responsible for any van rides that are not logged.
Frequent or continuous violations of these guidelines by case managers or
agencies may result in the suspension of access to transportation services by the
agencies clients.
Responsibilities of the AIDS Foundation of Chicago (AFC)
1. AFC will provide case management agencies with information on van service
agencies and the areas they serve.
2. AFC staff will maintain client central registries for transportation services.
3. AFC will notify agencies/case managers of any problems related to use of the
transportation services in a timely manner.
4. AFC will notify agencies if transportation funds for transportation services are
restricted or unavailable.
5. AFC will provide agencies with van service access as long as funds are available
and the agency has no other source for this resource.
6. AFC will notify the agency of any unauthorized ride or rides that violate the
established guidelines. Any unauthorized rides will not be paid for by AFC and
are the responsibility of the agency.
FORMS:
Please refer to van subcontractors for program-specific forms
CASE MANAGEMENT POLICY
Case Management Services
Subject: SOP 20 – Emergency Food Vouchers
Date: February 29, 2008 Page 1 of 3
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the provision of Ryan
White emergency food vouchers for clients with documented temporary emergent need in a way
that maximizes resources and standardizes the distribution of services.
POLICY: Cooperative subcontractors will receive from the AIDS Foundation of Chicago (AFC) a given
amount for food vouchers to be distributed to clients with a documented need.
PROCEDURE: Food vouchers are provided in $10 increments and must be distributed only for reasons aligned
with this policy as outlined below.
Eligibility
Clients will be eligible for emergency food vouchers if they meet the following criteria:
• Client’s income is at or below 50% of the area median income;
• Client affirms that they do not receive assistance from Public Aid (Link Card), or that the
assistance is inadequate to meet their nutritional need;
• Client affirms that they are not receiving food from Vital Bridges or any other Ryan
White-funded food pantry*; and
• Client affirms that they are not able to access other local food pantries*.
*Clients may receive food vouchers if they are accessing Ryan White or other funded food
pantries only if these sources do not meet the health or medical needs of the client, as indicated
by the client’s medical provider.
Clients must meet ALL of the above eligibility criteria to receive emergency food voucher
assistance.
Responsibilities of Client
1. The client must be enrolled in the AFC central registry and be receiving any level of case
management services, and must complete the Food Assistance Assessment on page 4 of the
Intake Form (SOP 3) or the Reassessment (SOP 8) prior to accessing emergency food
vouchers through the case management agency.
2. The client must cooperate with his or her case manager and apply for and use all appropriate
options for obtaining food assistance.
Responsibilities of Case Management Cooperative Agency
1. The case manager will assess the client’s long and short term food needs and available
resources utilizing AFC’s Food Assistance assessment tool. The case manager and client
will develop a plan to meet the client’s needs. The plan will be documented in the
client’s chart in the service plan and progress notes. Case managers will reassess client
food assistance needs on an ongoing basis (at least every six months).
2. As part of the assessment and planning process, the case manager will discuss with the
client other food assistance programs/options that are available and help the client apply
for other resources. Other sources of food assistance that could be used include:
• Link card;
• Neighborhood food pantries;
• Neighborhood soup kitchens; and/or
• Ryan White-funded grocery service.
3. Case managers must document in the client file when the AFC-funded emergency food
voucher is used and a rationale for why this was the preferred mode of assistance.
4. Each agency will have a contact person, whose responsibilities include enforcing
emergency food voucher guidelines and procedures, monitoring case manager’s use of
food vouchers, and submitting documentation of food voucher usage to AFC. The usage
of food vouchers are to be entered into the client-level database database.
5. The agency must follow up with the client when there are problems or misuse of the
AFC-funded emergency food vouchers. Repeated client misuse of the service will lead to
loss of assistance privileges.
6. The agency will be financially responsible for any food vouchers that are not logged or
are lost or stolen. Frequent or continuous violations of these guidelines by case managers
or agencies may result in the suspension of access to emergency food vouchers by the
agency.
Responsibilities of the AIDS Foundation of Chicago (AFC)
1. AFC staff will maintain client central registries for both case management and emergency
food vouchers.
2. AFC staff will distribute food vouchers based upon the availability of funding for this
service.
3. AFC will notify agencies/case managers of any problems related to use of the emergency
food vouchers in a timely manner.
4. AFC will notify agencies if funds for emergency food vouchers are restricted or
unavailable.
5. To reduce costs and foster client independence, AFC will provide agencies with food
vouchers as long as funds are available and the agency has no other source for this
resource.
6. AFC will notify the agency of any unauthorized use of food vouchers that violate the
established guidelines. Any unauthorized food voucher disbursements will not be paid
for by AFC and are the responsibility of the agency.
7. On a quarterly basis, AFC will report all food assistance data to the Ryan White funding
source.
FORMS:
CASE MANAGEMENT POLICY
Case Management Services
Subject: SOP 21 – Emergency Financial Assistance (EFA)
Date: June 22, 2006 Revised: February 29, 2008 Page 1 of 12
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding the requirements for the
Emergency Financial Assistance (EFA) program.
POLICY: The AIDS Foundation of Chicago (AFC) receives funding through Part A of the Ryan White Act
that provides limited emergency assistance for low-income persons. The EFA program exists to
assist individuals with maintaining housing stability, to assist those at risk of losing current
utilities, and assist those who are homeless to obtain stable housing.
PROCEDURE: Assistance may be provided one time per year per individual or household in the rent and/or
utility assistance category. Assistance will be provided based on the anniversary date of when the
client previously received emergency assistance (i.e. if a client received utility assistance on June
1, 2007, he/she would not be eligible for assistance until June 1, 2008.) AFC staff will monitor
the usage of emergency funds for clients. If it is believed that clients are inappropriately utilizing
the service as an entitlement, usage may be restricted and the client may be required to sign a
contract restricting future uses of EFA with the case manager.
All Cooperative case managers will complete the EFA application with clients who are
requesting assistance. Staff will complete the “Criteria for Emergency” checklist and give a
detailed explanation of the emergency/crisis situation and provide the appropriate
documentation. AFC will accept all 5-day notices of eviction, utility disconnection notices, letter
of homelessness from staff and/or housing advocate, lease and/or rental agreement as proof of
emergency. According to the Health Resources and Services Administration (HRSA), EFA
funds are to be used as “Payor of Last Resort”; therefore staff must submit documentation (Payor
of Last Resort Checklist) verifying that they and the client have exhausted all other possible
resources including other AFC-funded housing and emergency assistance programs.
Clients receiving Housing Assistance Program (HAP) and/or Long Term Rental (LTRS) rent
subsidies are not eligible for EFA.
PRIORITY CATEGORIES:
Any client requesting EFA will be assessed by a case manager and/or AFC Program Staff
member to determine his/her eligibility, including the priority based on the following criteria:
Category 1 HIV+ and disabled due to HIV
Category 2 HIV+ and disabled due to any cause
Category 3 HIV+ and not disabled
Documentation from a primary medical provider must be submitted with the application
verifying that the client is “disabled due to HIV” and unable to work full time. The only
acceptable proof of HIV disability is the Medical Assessment Form completed by a physician
within the last twelve months (see SOP 5B – Medical Assessment).
Depending on the amount of the EFA grant available to AFC and the number of clients
requesting assistance, from time to time, assistance may be limited to category 1 clients or
category 1 and 2 clients only. For information on the categories of assistance available at any
time contact an AIDS Foundation program staff member.
MAXIMUM LEVELS OF ASSISTANCE FOR RENT AND/OR UTILITIES
Individuals Rent or utilities (electric, gas and water): $800
Households Rent or utilities (electric, gas and water): $1,200
If applying as a household all adults living in the household unit must submit proof of their
income with the application. Minor children, under the age of 18, are not required to provide
proof of income.
In some exceptional cases, assistance will be made available to pay for telephone installation
and/or local telephone use. The case manager must contact AFC Program Staff before submitting
an application for telephone assistance.
In cases where documented need exceeds the above limits, the Cooperative case management
agency supervisor and AFC Program Staff will review the individual’s circumstances to
determine the level of assistance.
DISCRETIONARY ASSISTANCE CATEGORY
(ELIGIBLE TO OPEN AND ACTIVELY CASE MANAGED CLIENTS ONLY)
Limited funds may be available for assistance with emergency purchases of medications (with
physician approval). Written proof of emergency will be required with the full application.
Clients will ONLY be eligible for “discretionary assistance” funds when they have not applied or
received an EFA grant for rent and/or utility assistance in the last year.
Responsibilities of Client/Applicant
1. Clients may request EFA from a case management agency in the Cooperative or by
contacting AFC.
2. All applicants for EFA must make an application for assistance through a case
management agency in the Cooperative and be enrolled in the central client registry at
AFC.
3. Applicants must provide documentation that their household income is less than 50% of
the median household income in the Chicago metropolitan area for their household size
(per the official determination of the U.S. Department of Housing and Urban
Development).
4. Applicants must provide staff with adequate documentation that they are in an
emergency/crisis situation. AFC will accept all 5-day notices of eviction, utility
disconnection notices, letter of homelessness from agency staff and/or housing advocate,
lease and/or rental agreement as proof of emergency.
5. According to the Health Resources and Services Administration (HRSA), EFA funds are
to be used as “Payor of Last Resort”; therefore, staff must submit documentation (Payor
of Last Resort Checklist) verifying they and the client have exhausted all other possible
resources. Applicants must provide agency staff with written verification that no other
resources (e.g., HAP, The Homeless Prevention Fund, Salvation Army, Catholic
Charities, CEDA and/or Township Assistance are available to pay for emergency needs.)
Responsibilities of Case Management Cooperative Agency
1. The case manager or agency designee will screen applications for eligibility and priority
category. If the applicant is not a case managed client, he/she must be offered case
management services, or referred to AFC for screening for service eligibility for
Cooperative services.
2. If the client meets the eligibility criteria and priority category but does not wish to enroll
in case management services, agency staff must complete an EFA application, including
the EFA intake form and with the verifying documentation, and present the case to the
supervisor or designated agency administrator for on-site approval.
3. The case manager or agency designee will forward the application with all the required
documentation to the identified AFC Program Staff.
4. The case manager or agency designee will obtain approval and an authorization number
from an AFC Program Staff.
5. EFA payments for all clients must be addressed in a timely manner and payments made
within 5 working days of approval.
6. No payments will be made directly to the applicant/client; all payments will be made
directly to a third party/vendor (i.e. landlord or utility company). The agency must have
documentation on file (such as receipts) that funds were used for the purpose intended.
7. The agency will submit the request for reimbursement along with documentation of the
disbursement and the AFC authorization number within 5 working days of expenditure of
funds.
Responsibilities of the AIDS Foundation of Chicago (AFC)
1. AFC will screen non-case managed applicants who contact AFC directly to determine if
they meet the eligibility criteria and priority category. All applicants will be advised that
they may be eligible to receive case management services regardless of their eligibility
for EFA.
2. If the client meets all of the eligibility criteria, AFC will refer them to a Cooperative case
management agency to complete an EFA intake and application.
3. AFC will maintain and update the client central registry of currently enrolled
clients as a means of ensuring timely approval of requests.
4. AFC will provide the agency with an authorization number for all approved
requests.
5. AFC will provide the agency with a verbal and, in some cases, written explanation for
any requests not approved.
6. AFC will process any and all approved reimbursement requests with adequate
documentation in a reasonable and timely manner.
7. AFC will notify funded agencies if and when all available funds for this program have
been expended and/or if eligibility will be temporarily limited to certain categories.
FORMS:
EFA Intake Form
Budget Form for Emergency Assistance
EFA Criteria for Emergency Checklist
EFA Payor of Last Resort Checklist
EFA Client Request for Assistance
EFA Request for Reimbursement Form
AIDS FOUNDATION OF CHICAGO
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANAGEMENT COOPERATIVE
EMERGENCY FINANCIAL ASSISTANCE INTAKE FORM APPLICATION DATE: ____ ____ / ____ ____ / ____ ____ CLIENT ID #: ___________________________ AGENCY: _____________________________ STAFF: ______________________
REFERRAL SOURCE:
AFFILIATION:
PHONE #: ( ) ______________
LAST NAME: __________________________ FIRST: __________________________ MI:_______
DOB:_____ / _____ / _____ GENDER: M F PHONE: ( ) ______________
ADDRESS: ___________________ CITY: _______________ COUNTY: _________ ZIP:__________
SS#: __ __ __ - __ __ - __ __ __ __ MOTHER'S MAIDEN NAME: ____________________________
EMERGENCY CONTACT: _______________ RELATIONSHIP: _______________ PHONE: ( ) ______________
IS EMERGENCY CONTACT AWARE OF DIAGNOSIS? YES NO (please circle one)
--CHECK ONLY ONE IN EACH OF THE FOLLOWING CATEGORIES-- --SHADED AREAS ARE FOR NON-CASE MANAGED CLIENTS ONLY.--
INCOME SOURCE (CHECK ALL THAT APPLY)
YES NO EMPLOYMENT ____ ____
TANF ____ ____ FOOD STAMPS ____ ____
SSI ____ ____ SSDI ____ ____
UNEMPL COMP ____ ____ WORKERS COMP ____ ___
CASE #____________________ NO ENTITLEMENTS ________ OTHER____________________
ETHNICITY:
Hispanic/Latino/a Yes ____ No ____
Mexican ____
Puerto Rican ____ Other Hispanic ____
RACE: WHITE _____
BLACK/AFRICAN AMERICAN _____ ASIAN _____
HAWAIIAN/PACIFIC ISLANDER _____ AMERICAN INDIAN _____
MORE THAN ONE RACE _____ UNKNOWN _____
SEROSTATUS:
AIDS DIAGNOSIS _____
HIV+/ NOT AIDS _____ HIV+/ AIDS UNKNOWN _____
HIV NEGATIVE _____ UNKNOWN _____
RISK FACTOR:
HOMOSEXUAL/BISEXUAL _____ IDU _____
HOMOSEXUAL/IDU _____ HETEROSEXUAL _____
TRANSFUSION _____ HEMOPHILIA _____
PARENT HIV+ _____ UNKNOWN _____
MONTHLY HOUSEHOLD INCOME
$_________________
TOTAL NUMBER OF INDIVIDUALS IN HOUSEHOLD
(ATTACH PROOF OF INCOME)
INSURANCE SOURCE:
PRIVATE _____ MEDICAID _____
MEDICARE _____ OTHER PUBLIC _____
MORE THAN ONE _____ NONE _____
CO. ______________________ GROUP ID# _______________ IND. ID# __________________
PRIMARY CARE SOURCE:
PRIVATE PRACTICE _____ HMO _____
COMMUNITY HEALTH CTR. _____ HOSPITAL CLINIC _____
OTHER CLINIC _____ EMERGENCY ROOM _____
OTHER _____ NONE _____
LIVING ARRANGEMENT:
PERMANENT HOUSING _____ NON-PERMANENT
HOUSING _____ INSTITUTIONALIZED _____
OTHER _____ UNKNOWN _____
SOURCE OF REFERRAL:
CASE MANAGER _____ COURT SYSTEM _____
DCFS _____ FAMILY & FRIENDS _____
HIV COUNSELING AND TESTING SITES _____
HOTLINE _____ MEDIA _____
OTHER AGENCY _____ OTHER UNIT IN PROVIDER
AGENCY_____ PRIMARY CARE
PROVIDERS_____ STD CLINICS _____
SELF-REFERRAL _____
RENTAL ASSISTANCE: � I certify that the emergency
rental/housing assistance for this client will help to provide access to direct medical or support services, including, but not limited to, residential substance abuse or mental health services.
AND/OR
� I certify that emergency rental/housing assistance is transitional in nature and is for the purpose of moving or maintaining an individual or family into a long-term, independent living situation.
Approved by Case Management Governance Committee on June 22, 2006
Application Page 2
Client Name _________________________
Please complete service plan indicating types of assistance/referrals that can be made through case management services. REFERRALS NEEDED
SERVICE/NEED YES*
NO*
SERVICE
REQUESTED
CASE MANAGER COMMENTS
ALTERNATIVE THERAPIES
Y / N
CASE MANAGEMENT
Y / N
DAY & RESPITE CARE
Y / N
DENTAL CARE
Y / N
DIRECT EMERGENCY ASSISTANCE
Y / N
DRUG REIMBURSEMENT PROGRAM
Y / N
ENTITLEMENTS
Y / N
FAMILY ISSUES
Y / N
FOOD SERVICE
Y / N
HOME HEALTH CARE
Y / N
HOSPICE CARE
Y / N
HOUSING SERVICE/RESIDENTIAL
CARE
� Shelter Plus Care Program � Affordable Housing Search � Independent Living Program
� Referral to Housing Advocate
� Employment Assistance
� Home Purchasing Program � Public/Assisted Housing � Section 8 � Other ___________________
Y / N
HOUSING SERVICE/RENT SUBSIDIES
� HAP Program
Y / N
INFORMATION DISSEMINATION
Y / N
INPATIENT CARE
Y / N
LEGAL SERVICES/ADVOCACY
Y / N
MENTAL HEALTH SERVICES
Y / N
PRIMARY CARE
Y / N
SUBSTANCE ABUSE
Y / N
TRANSPORTATION
Y / N
VOCATIONAL/EMPLOYMENT
Y / N
VOLUNTEER SERVICES
Y / N
Approved by Case Management Governance Committee on June 22, 2006
Application Page 3
AIDS FOUNDATION OF CHICAGO
BUDGET FORM FOR EMERGENCY ASSISTANCE
Client Name Date ____________ Completed by _____________
I. HOUSEHOLD INCOME PRESENT INCOME POTENTIAL INCOME Earned income ________________
SSI/SSDI
Public Aid
Unemployment Compensation
Food stamps
Child support
Other
TOTAL
CURRENT LIQUID ASSETS
Savings ________________ ________________
Checking ________________ ________________
Cash ________________ ________________
Life Insurance Policy ________________ ________________
Other ________________ ________________
TOTAL ________________ ________________
II. EXPENSES CURRENT OLD DEBT PRESENT EXPENSES BUDGETED
EXPENSES Rent/mortgage ________________ ________________ ________________
Electric ________________ ________________ ________________
Gas ________________ ________________ ________________
Water ________________ ________________ ________________
Sewer ________________ ________________ ________________
Phone ________________ ________________ ________________
Transportation ________________ ________________ ________________
Food & Personal ________________ ________________ ________________
Cleaning/laundry ________________ ________________ ________________
Recreation ________________ ________________ ________________
Day care ________________ ________________ ________________
Car payment ________________ ________________ ________________
Car insurance ________________ ________________ ________________
Medical/insurance ________________ ________________ ________________
Other__________ ________________ ________________ ________________
Totals: ________________ ________________ ________________
III. BUDGET DEFICIT = ACCUMULATED CURRENT EXPECTED ________________ ________________ ________________ IV. FINANCIAL SERVICE PLAN (address what steps will be taken to remove debt, address budget deficit, maximize income and
maintain stability - use back, if necessary)
Category (Check one) � Category 1 HIV+ and disabled due to HIV
� Category 2 HIV+ and disabled due to any cause
� Category 3 HIV+ and not disabled
Approved by Case Management Governance Committee on June 22, 2006
Application Page 4
AIDS Foundation of Chicago
Northeastern Illinois HIV/AIDS Case Management Cooperative
Emergency Financial Assistance “Criteria for Emergency” Checklist
Client Name: Person Completing Form:
Explanation of Emergency and Financial Service Plan:
Description of Emergency/Crisis: (check all that apply)
□ Unable to pay rent – 1 month past due (no eviction notice)
□ Unable to pay rent – 2 months past due (no eviction notice)
□ Unable to pay rent – 3 months past due (no eviction notice)
□ Received 5-day eviction notice
□ Received electric bill disconnection notice
□ Received gas bill disconnection notice
□ Received phone bill disconnection notice
□ Homeless and needs assistance with first month’s rent
□ Unable to afford to fill medication prescription(s)
□ SSI/SSDI Pending (with documentation)
□ Housing situation is unsafe for client
□ Domestic violence situation (with police report)
□ Other (please specify):
I verify that the above information is accurate to the best of my knowledge.
Client Signature:
Agency Staff/Housing Advocate Signature:
Date:
Approved by Case Management Governance Committee on June 22, 2006
Application Page 5
AIDS FOUNDATION OF CHICAGO
NORTHEASTERN ILLINOIS HIV/AIDS CASE MANGAEMENT COOPERATIVE
EMERGENCY FINANCIAL ASSISTANCE “PAYOR OF LAST RESORT” CHECKLIST
Name of Agency Date Contacted Outcome (If not applicable
please state)
Salvation Army
(773) 725-1100
The Homeless Prevention Fund
(773) 329-4500
CEDA
(312) 853-5960
Catholic Charities
(312) 655-7700
Other
I verify that the above information is accurate and that I have tried every resource possible before submitting this
application with my case manager.
Agency Staff Name: Agency Staff Signature:
Date:
Client Name: Client Signature:
Date:
Additional Staff Comments:
Approved by Case Management Governance Committee on June 22, 2006
Application Page 6
AIDS FOUNDATION OF CHICAGO EMERGENCY FINANCIAL ASSISTANCE REQUEST
Fill one of these out for each request for assistance.
CLIENT REQUEST FOR ASSISTANCE I am asking the AIDS Foundation of Chicago to help pay my bills. I need $_______________ to pay for: ________________________________________________________. The payment must be made no later than ________________________________. The reason I cannot pay for this myself is that I have insufficient funds as I have documented on the attached budget sheet. I give you permission to send the check directly to the person or company I owe money and to ask for a receipt. (initial or sign here) _______________ The information I have given you about my income, my expenses, my savings and my household is true. I understand that in signing this application and requesting this assistance, my name will be placed in AFC’s Northeastern Illinois HIV/AIDS Case Management Cooperative Central Registry. I understand that the Emergency Financial Assistance program is not an entitlement program and that I am not guaranteed to receive assistance every year. I further understand that if I have utilized these funds on a yearly- basis in the past, I may be asked to sign a contract with my case manager agreeing not to re-apply for a designated period of time. MY SIGNATURE ________________________________ MY PRINTED NAME ________________________________ MY ADDRESS _______________________________
________________________________ MY PHONE NUMBER _______________________________ MY SOCIAL SECURITY NUMBER ________________________________ MY DATE OF BIRTH ________________________________ TODAY’S DATE ________________________________ EFA Application Checklist: (make sure all of these are included with the application)
� EFA Application Page 1- � EFA Application Page 2 (for rent requests, include follow-up housing plan) � EFA Budget Form � EFA Client Request for Assistance Form � EFA Agency Reimbursement Form � Documentation of emergency: (5-day notice, disconnection, homeless letter) � Proof of HIV disability � Proof of income
Approved by Case Management Governance Committee on June 22, 2006
Application Page 7
FUNDACION DE SIDA DE CHICAGO
SOLICITUD DE ASISTENCIA DE EMERGENCIA
Llene una de estas aplicaciones por cada solicitud de emergencia.
SOLICITUD DE ASISTENCIA DE EMERGENCIA
Estoy pidiendo a la Fundación de SIDA de Chicago ayuda para pagar gastos de emergencia. Necesito
$_______________ para pagar ________________________________________________________. El pago
debe hacerse a más tardar________________________________. La razón por la que no puedo pagar esta
cuenta yo mismo, es porque no tengo suficientes ingresos, tal y como ha sido documentado en el presupuesto
adjunto.
Yo autorizo que el pago se envíe directamente a la persona o compañía a quien le debo el dinero y a solicitar un
recibo/comprobante de pago. (Ponga sus iniciales o firma aquí) _______________
La información que he proveído acerca de mis ingresos, mis gastos, mis ahorros y mi familia es correcta.
Entiendo que al firmar y solicitar esta asistencia, mi nombre será incluido en el archivo de la Cooperativa de
manejo de caso de la Fundación de SIDA de Chicago para facilitar las funciones administrativas.
Yo entiendo que el programa de Asistencia Financiera de Emergencia no es un programa de derecho adquirido
y por lo tanto no esta garantizado que reciba esta asistencia cada año. Yo entiendo además que si en el pasado
he usado estos fondos de emergencia en exceso, se me podría solicitar firmar un contrato con mi manejador de
caso, en el que estoy de acuerdo en no reaplicar por un determinado periodo de tiempo.
FIRMA ________________________________
NOMBRE ________________________________
DIRECCION ________________________________
NUMERO DE TELEFONO ________________________________
NUMERO DE SEGURO SOCIAL ________________________________
FECHA DE NACIMIENTO ________________________________
FECHA ________________________________
ECA- Lista de documentos: (Por favor incluya todas estas formas con su aplicación) � Aplicación de Asistencia de Emergencia-Pagina 1 � Aplicación de Asistencia de Emergencia-Pagina 2 (Para solicitud de renta, incluya su plan de
Vivienda) � Presupuesto � Forma de Solicitud de Asistencia � Forma de Reembolso � Documentación de emergencia: (forma de desalojo notariada, desconexión, carta de refugio) � Prueba del estado medico � Prueba de ingresos
Approved by Case Management Governance Committee on June 22, 2006
Application Page 8
AIDS Foundation of Chicago
Emergency Financial Assistance Reimbursement Form
Client FACTORS ID:_____________________ Client Name:_______________________
Category (Circle one) Category 1 HIV+ and disabled due to HIV
Category 2 HIV+ and disabled due to any cause
Category 3 HIV+ and not disabled
Case Management Agency: _____________________________________________________
Amount: ___________________ AFC Authorization #:______________________________
AFC Program Associate: _________________ Authorization Date: ___________________
Payee Name: ____________________________________________________________
Address: ____________________________________________________________________
City, Zip:____________________________________________________________________
Purpose: Rent/Housing: Eviction ___ 1st Months Rent _____ Basic Telephone
Service:_____ Gas: _____ Electric: _____
Check documentation on file:
Lease/Rental Agreement: ___ Utility Bill: __Other:________________________________
Agency Authorized Signature: __________________________ Date: _____________________
Please copy agency check in this space (or attach copy to this form)
DON’T FORGET TO SIGN WHERE IT SAYS AGENCY AUTHORIZED
SIGNATURE!
REQUEST FOR REIMBURSEMENT MUST BE SUBMITTED TO AFC WITHIN
5 DAYS OF PAYMENT
PLEASE COMPLETE ONE FORM FOR EACH ASSISTANCE REQUEST. ALL PAYMENTS MUST BE MADE WITHIN FIVE DAYS OF AUTHORIZATION DATE.
CASE MANAGEMENT POLICY
Case Management Services
Subject: SOP 22 – Language Translation Services
Date: July 27, 2005 Revised: February 29, 2008 Page 1 of 4
PURPOSE: To set a minimum standard across Cooperative subcontractors regarding a policy for case
managers to access translation services for their clients who are in need of American Sign
Language (ASL) interpretation or those clients who are not functionally proficient in the English
language.
POLICY: Clients will have access to translation services so that they may participate in case management
service as coordinated through the AIDS Foundation of Chicago (AFC) regardless of primary
language spoken, including American Sign Language.
PROCEDURE: Foreign Language Translation
Case managers will use the services of the AFC-identified translation provider to request foreign
language translation services. Case managers will contact AFC to schedule translation services
and will report this utilization to AFC.
During intake or reassessment, case managers will inquire of all non-English speaking clients
whether they prefer to have translation services available for their case management office visits.
If clients express the desire to provide their own translation services, either through a friend,
family member, or significant other, the case manager will request that the client sign a release of
information to allow that individual to obtain confidential client service information. The case
manager will also notify the client that if they choose their own translation services, the case
management agency does not accept any liability for the quality of those translation services.
If the client does not express the desire to provide their own translation services, the case
manager will contact AFC to receive approval for foreign language translation services.
The case manager will then complete the Foreign Language Translation Request Form
and submit it to AFC’s designated Program Staff member at least three business days in advance
of the service needed. The case manager will also notify the AFC’s designated Program Staff
member if the service was unable to be provided due to translator-related issues.
American Sign Language
Case managers will use the services of the AFC-identified translation provider to request sign-
language translation services. Case managers will contact AFC to schedule translation services
and will report this utilization to AFC.
During intake or reassessment, case managers will inquire of all hearing impaired clients whether
they would prefer to have professional sign-language translation services present and available
for their case management office visits. If clients express the desire to provide their own
translation services, either through a friend, family member, or significant other, the case
manager will request that the client sign a release of information to allow that individual to
obtain confidential client service information. The case manager will also notify the client that if
they choose their own translation services, the case management agency does not accept any
liability for the quality of those translation services.
If the client does not express the desire to provide their own translation services, the case
manager will request an interpreter through AFC by filling out the Sign Language Interpretation
Request Form and submitting it to the designated Program Staff member at AFC at least five
business days before the service is needed. The Program Staff member will approve or deny the
request, schedule the interpreter, and will sign the form and return to the case manager as
confirmation that the service has been approved. The Program Staff member will also notify the
case manager of any complications to the service by the translation provider.
FORMS: Foreign Language Translation Request Form
Sign Language Interpretation Request Form
Foreign Language Translation Request Form
Case Management Agency Name: _________________________________________________
Case Manager Name: ___________________________________________________________
Date Completed: _______________ Requested Date of Service: ___________________
Foreign Language Needed: _______________________________________________________
Client Name: __________________________________________________________________
Visit Type: Intake _____ Reassessment _____ On-going case management contact ______
Issues to be addressed in case management encounter: (Please include a brief narrative regarding
the areas of service detailed in the encounter)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Will the case manager be requesting this service again for this client?:
Yes _______ No ______
Anticipated frequency of translation service request for this client: _______________________
AFC Staff Signature: ____________________________________________________________
Date: ________________________________________________________________________
Vendor: ______________________________________________________________________
Complete this form for every individual translation request and fax to Program Coordinator at the AIDS Foundation (312) 922-2916 for approval. Service may not be rendered without prior approval.
Sign Language Interpretation Request Form
Case Management Agency Name: _________________________________________________
Case Manager Name: ___________________________________________________________
Date Completed: _______________ Requested Date of Service: ___________________
Client Name: __________________________________________________________________
Visit Type: Intake _____ Reassessment _____ On-going case management contact ______
Issues to be addressed in case management encounter: (Please include a brief narrative regarding
the areas of service detailed in the encounter)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Will the case manager be requesting this service again for this client?:
Yes _______ No ______
Anticipated frequency of translation service request for this client: _______________________
AFC Staff Signature: ____________________________________________________________
Date: ________________________________________________________________________
Vendor: ______________________________________________________________________
Complete this form for every individual translation request and fax to Program Coordinator at the AIDS Foundation (312) 922-2916 for approval. Service may not be rendered without prior approval.