Medical Case Management is the provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Activities may be prescribed by an interdisciplinary team that includes other specialty care providers. Medical Case Management includes all types of case management encounters (e.g., face-to-face, phone contact, and any other forms of communication). Key activities include: 

• Initial assessment of service needs 

• Development of a comprehensive, individualized care plan 

• Timely and coordinated access to medically appropriate levels of health and support services and continuity of care 

• Continuous client monitoring to assess the efficacy of the care plan

• Re-evaluation of the care plan at least every 6 months with adaptations as necessary

• Ongoing assessment of the client’s and other key family members’ needs and personal support systems 

• Treatment adherence counseling to ensure readiness for and adherence to complex HIV treatments 

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