Ryan White CARE 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:

  • Intake 
  • Assessment 
  • Reassessment 
  • 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:

  1. The Ryan White Program Intake form will be completed in its entirety.
  2. 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.
  3. The client’s Informed Consent to Participate in the case management program shall be  obtained.
  4. The client will be informed of their right to confidentiality and information privacy procedures.
  5. 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.
  6. The client will be informed of, and agree to the Client’s Rights and Responsibilities form.
  7. The client will be informed of an agency’s as well as the Ryan White Program’s Grievance Procedure.
  8. The client will be informed of the role and purpose of case management.
  9. 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).
  10. 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:

  1. 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.

  2. 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:

  1. The Care Plan is adequate  to meet client needs; 
  2. The client is actively pursuing Care Plan objectives;
  3. Care is coordinated; and
  4. 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. 

GRS Agency/Council Grievance Procedures

Here at Golden Rule Services we strive to provide our clients with excellent care. However, in cases
where a client has concerns regarding the quality of his/her service provisions, the case will be reviewed
through the agency’s and the HIV Health Services Planning Council’s specific grievance procedures. The
grievance phases are outlined below.

  • Phase one: client and Case Manager are encouraged to informally resolve any dispute.
  • Phase two: if both parties are unable to adequately resolve the grievance, the client will submit
    in writing (within 10 working days) to the Director of Golden Rule Services, the nature of the
  • Phase three: if a resolution is not mutually resolved between the client and agency, the case will
  • then be reviewed by the Recipient.
  • Phase four: a written response will be sent to all parties involved (e.g. agency, client) within
    twenty (20) working days with a disposition.
  • Phase five: if an extension is needed, a letter shall notify all parties involved of an extension for
    an additional ten (10) working days.
  • Phase six, a final disposition shall occur no later than thirty (30) working days following the initial
    filing with FAA.
    CLICK HERE to download a PDF containing the full information about GRS’ grievance procedures.