The Ryan White HIV/AIDS Program
Golden Rule Services is proud to be a recipient of the Ryan White HIV/AIDS Program, helping those living with HIV/AIDS in our community, and helping to prevent new HIV infections. We are also proud to be doing out part to educate and protect people living with HIV during the COVID-19 pandemic.
To learn more about protecting yourself and getting tested for COVID-19 in the Sacramento County area, please click here.
Case Management Processes
After a referral for case management has been triaged among agency staff, the core activities of case management are:
- Care Plan Development
- Care Plan Implementation
- Care Plan Follow-up and Monitoring
- Transfer and Discharge
- Evaluation of Client Satisfaction
Each prospective client who requests or is referred for Case Management services will be properly screened and evaluated through a face-to-face intake process designed to gather information for future service delivery and assist in decision-making regarding immediate needs. The service request/referral will be screened for basic admission criteria and assesses whether the client is in a crisis situation and/or requires immediate direct service referral. If immediate intervention is needed, the client shall be immediately referred to the appropriate entity. At minimum, the following activities will take place during initial intake:
- The Ryan White Program Intake form will be completed in its entirety.
- The client will be assessed with an Acuity scale which will be dated and signed by the case manager. The acuity scale will be updated every 6 months.
- The client’s Informed Consent to Participate in the case management program shall be obtained.
- The client will be informed of their right to confidentiality and information privacy procedures.
- The client will be informed of the Release of Information Form, and will be asked to provide consent to the appropriate release of information to other pertinent entities. Additionally, the Release of Information Form must be updated annually.
- The client will be informed of, and agree to the Client’s Rights and Responsibilities form.
- The client will be informed of an agency’s as well as the Ryan White Program’s Grievance Procedure.
- The client will be informed of the role and purpose of case management.
- Assuming basic eligibility, the client may proceed to formal assessment, or be referred to another Case Management agency (if the client would be better served based upon their particular need for case management services).
- Create a client file and archive all relevant documents and forms.
Each client of Case Management services will participate in at least one (1) initial face-to-face interview with a Case Manager to assess their bio-psychosocial needs. The assessment will be used to collect, analyze, and prioritize information which identifies client needs, resources, and strengths for purposes of developing a Care Plan. Assessment will be conducted by a Case Manager and performed in accordance with written policies and procedures established by the individual Ryan White provider utilizing appropriate Ryan White Program forms (including the Client Intake Form), as required.
Care Plan Development
A Care Plan shall be developed, in consideration with the Acuity scale, in an interactive process with each client. Development of the Care Plan is a translation of the information acquired during Intake and Assessment into specific measurable goals and objectives with defined activities and time frames to reach each objective. The Care Plan outlines interventions and services that will allow the client to overcome barriers and fulfill their needs, and identifies strategies and action plans for implementing those interventions and accessing needed services. The Care Plan will include explanations of referral and follow-up and realistic objectives and goals to be achieved by program compliance. The client and Case Manager will work together to decide what actions are necessary to accomplish each objective and who will take responsibility for each task.
The client and Case Manager must review and mutually agree to all goals and objectives outlined in the Care Plan. Following this process, the client and Case Manager must sign and date the Care Plan. If an electronic medical record exists in lieu of a paper file, the Case Manager will document in the client’s electronic medical record that the CARE Plan has been mutually agreed to by the client and the Case Manager.
In accordance with US Department of Health Resources and Services Administration new performance measures:
- The Care Plan must be updated two or more times during the measurement year, unless the client initiated services within six months prior to the end of the measurement year.
For example: The Sacramento TGA fiscal year is March through February. If a client entered services in December, only the initial Care Plan would be feasible during the measurement year of March – February.
- The Case Manager shall document the client’s HIV medical visits during the measurement year.
Care Plan Implementation
The Case Manager shall be available to assist the client in facilitating access to services when needed and/or provide advocacy assistance to help problem solve as necessary when barriers impede access. The Case Manager will always first attempt to encourage clients to resolve their challenges, and support clients in thinking through solutions before acting on behalf of the client to achieve care plan objectives. Referral agencies shall be assessed for appropriateness to client situation, lifestyle, and need. The referral process shall include timely follow-up of all referrals to ensure that services are being received. Agency eligibility requirements shall be considered as a part of the referral process. Any referral made shall be appropriately documented in the client record.
Care Plan Follow-Up and Monitoring
Periodic Care Plan follow-up and monitoring will be used to ensure that:
- The Care Plan is adequate to meet client needs;
- The client is actively pursuing Care Plan objectives;
- Care is coordinated; and
- Changing or emerging needs are being addressed. The Care Plan should be signed and dated by both the case manager and client at the time of each update. If an electronic medical record exists in lieu of a paper file, the Case Manager will document in the client’s electronic medical record that the Care Plan has been mutually agreed to by the client and the Case Manager at the time of each update.
The Care Plan must be updated two or more times during the measurement year, unless the client initiated services within six months prior to the end of the measurement year. If the Care Plan remains appropriate and no revisions are made, the Case Manager should document that the Care Plan has been reviewed and no changes were indicated. It is recommended that clients indicate either acceptance or review of their Care Plan, regardless of whether changes were made.
Clients receiving Case Management services will have their needs reevaluated through a comprehensive psychosocial reassessment and acuity scale reassessment. Reassessment shall occur at a minimum of every six months. The reassessment will be used to identify current RW eligibility, resolved issues, unresolved issues, and emerging need as compared to the prior assessment, and will guide appropriate revisions in the Care Plan, and make informed decisions regarding discharge from Case Management services and/or transition to other appropriate services. Reassessment will be conducted utilizing the same process outlined for initial assessment.