AFC is proposing a reconfigured case management continuum, which will expand the capacity of the case management system to serve more clients, stabilize or improve client health indicators, improve adherence to appointments and medication, and respond to new federal guidelines that re-define case management include treatment coordination.

Background
In light of growing nationwide recognition that case management has been identified by HRSA as a “core service” that facilitates linkage to and maintenance of primary medical care services, the AIDS Foundation of Chicago (AFC) and the Chicago Department of Public Health (CDPH) in consultation with Training Resources Network, Inc. (TRN) are taking a leadership role to develop a new system of case management services that responds to changes in the Ryan White HIV/AIDS Treatment Modernization Act, is responsive to the levels of need of clients in the Chicago EMA, and maintains many of the successful characteristics of the current case management system. This new system will emphasize treatment and appointment adherence, to better coordinate treatment for clients to ensure appropriate access to and utilization of clinical services , and monitor health outcomes with the goal of supporting clients as they become partners in their own self care.

In 2003, the Chicago Department of Public Health (CDPH), the Chicago Area HIV Services Planning Council, and the AIDS Foundation of Chicago (AFC) agreed that the system of case management in the Chicago EMA should be evaluated and revised. The most significant factor influencing this process is the need to devote limited resources in the most effective manner to serve the highest need clients. Case management has been defined by HRSA and current Ryan White Act Re-Authorization language as a “core service” (medical case management) whose purpose is to facilitate linkages and maintenance of primary care and other core services.

In addition to increased need for case management services to link to primary care, Chicago is facing a strain on its ability to provide traditional social case management to all eligible clients who request it. Approximately 1,600 new cases of HIV are diagnosed in Illinois each year, and yet the resources for case management and other HIV-specific services are expected to be either level or on the decline. Additionally, the CDC estimates that approximately 25% of all infected people do not know their status, and another 25% are not actively engaged in medical care. As prevention and care programs strive to enroll newly-tested clients into care, the need for services is only going to increase. The current system of care must be revised in order to adequately meet this demand.

New Case Management Continuum
In an effort to address these environmental factors, to retain what works in the current case management system, and improve the quality of services provided, AFC and CDPH are testing a reconfigured case management continuum, which will expand the capacity of the case management system to serve more clients, stabilize or improve client CD4 counts and viral loads, and improve adherence to appointments and medication, among other outcomes. This newly retooled case management continuum will be comprised of three distinct levels of case management between which clients can move depending on their individual level of need.

• Intensive Case Management (ICM) targets clients with exceedingly high levels of need. The programs include but are not limited to people living with HIV who are post- corrections/post-incarceration, pregnant women living with HIV, and chronically-ill homeless individuals. ICM focuses on stabilizing clients, facilitating active links to primary medical care and other core services, and emphasizing treatment and appointment adherence.
• Medical Case Management (MCM) focuses on facilitating active links to primary medical care and other core services with an added emphasis on treatment and appointment adherence.
• Supportive Services Case Management (SSCM) will serve clients with low need and who are medically stable, but occasionally require only basic assistance from case managers.

Implementation Plan
In order to bring the Northeastern Illinois Case Management Cooperative in line with the HRSA service definitions for case management including treatment adherence, AFC has outlined a timeline of activities. This timeline assumes the roll-out of the two key components of this new service definition of case management: (1) assessing and tracking treatment readiness and adherence, and (2) based on the information gathered, coordinating health care services for people living with HIV. AFC will work to integrate treatment coordination methods that will aim to increase communication between case managers and clinical providers in an attempt to institutionalize ongoing dialogue between the two groups of providers.

The timeline outlines the following activities associated with the implementation:

• Integration of Treatment Coordination : AFC will identify and evalutate treatment coordination methods (including, but not limited to case conferencing, telephone coordination, and patient care liaisons) that providers currently utilize in the case management system.
• Case Manager Training and System Capacity Building: AFC will be providing technical assistance and training to the system (case managers, supervisors, and agencies) to assist them in adapting their current case management program to meet HRSA’s definition.
• Tool Implementation: AFC will be implementing assessment and tracking tools including a revised acuity scale, medical assessment, and intake. In addition, AFC will be developing medication and treatment adherence assessments and treatment readiness assessments.
• Communications Plan and Consumer Education: To ensure adequate buy-in into the new system and to manage community expectations of case management services, AFC will ensure consistent communication with stakeholders throughout each stage of this implementation process. A specific focus will be targeted towards clients, case managers, and the clinical community.

As we implement these pieces of a newly developed case management continuum, AFC will be soliciting community input into framing the overall program design. Ultimately, the goal of this project will be to rebid the new case management continuum services in a competitive Request for Proposals (RFP) process in early Spring 2008.