Case Management

Case Management Model 

Case Management Model

AFC’s case management system provides a wide range of services to nearly 7,000 people each year through direct services and partner organizations. Case managers act as a connection and navigator between clients and services. Our system identifies medical (including HIV treatment and prevention), social service, substance use, employment and housing needs as wraparound services. Case managers assist clients in applying for benefits, including housing, transportation, food and nutrition services. AFC also facilitates access to emergency homelessness prevention funds in times of crisis; and refers to other organizations and services as needed.

AFC’s case management model is unique in the U.S. because of its coordinated system. This means that each client in the system has only one case manager who is trained to provide the client with a wide variety of services and referrals depending on the client’s needs. The coordinated system also allows for standardized training of all case managers along with one set of Standard Operating Procedures for use across the entire system.

AFC’s case management program continues to address the unmet health needs of persons living with HIV and AIDS In fact, 86% of people in AFC’s Ryan White case management program are virally suppressed.Viral suppression supports one’s individual and community health, as someone who is virally suppressed is healthier and cannot pass HIV sexually to their partners – this is known as U=U or Undetectable=Untransmittable.

As a part of the coordinated system, AFC utilizes a central database of client demographic, information and outcomes such as viral suppression rates, which gives AFC the ability to report out on unduplicated client encounters. The goal of case management is to be a standardized process of assessment, case planning, service coordination, referral, advocacy and follow-up, through which the multiple service needs of people affected by HIV are met.

In our role as the coordinating body for case management, AFC: 

  • Solicits, administers and reports on public and private funds for case management through quarterly reports to the Chicago Department of Public Health, which funds Ryan White Part A; the Illinois Department of Public Health, which funds Ryan White Part B; and the Illinois Department of Human Services’ Division of Rehabilitation Services, which funds DRS case management, as well as transportation and emergency assistance 
  • Establishes contracts with direct-service agencies 
  • Develops and administers policies and procedures, and communicate changes in the HIV environment to all subcontractors on a regular basis 
  • Maintains a central client database 
  • Ensures quality and consistency of case management services by having new case managers attend a 40-hour Competencies Training and attend 12 skills-building trainings each year, as well a robust quality management program including annual site visits 
  • Provides bilingual information and referral 
  • Provides training and technical assistance 
  • Provides staff support to the case management collaborative leadership council 
  • Monitors key client outcomes to including viral suppression and housing stability rates to ensure clients are able to be as healthy as possible 
  • AFC strives to be the leader in providing services appropriate to our clients’ changing needs. 
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