Case Management Services

Program Description

The Bureau of Community Support Services oversees the COBRA Community Follow-Up Program, Ryan White Part B case management contracts, the case management training initiative, and the case management outcomes and quality improvement project. The Bureau also serves as a resource to the AIDS Institute and community agencies regarding case management systems and program development.

Community Follow-Up Program (COBRA)

The Community Follow-Up Program (COBRA), implemented in 1990, is a statewide initiative under Comprehensive Medicaid Case Management. The program provides family-centered, intensive case management services. The targeted Medicaid-eligible populations include HIV-infected persons and their families, and high-risk individuals for a temporary period of time. The Community Follow-up Program (CFP) model utilizes a team of case managers and paraprofessionals to provide more comprehensive and intensive case management.

The program is designed for persons who have comprehensive service needs, require frequent contact with care providers and have had difficulty accessing medical care and supportive services either due to issues with follow-up or because of barriers to service. Program goals are to provide access to services that foster independence and self-sufficiency, work to ensure adherence to care and treatment, prevent or delay institutionalization, increase universal access to HIV-related services and to promote early intervention.

Eligible providers include Article 28 providers, certified home health agencies, community health centers, AIDS Community Services Programs and other community-based organizations with two years experience in case management of HIV-positive persons. Also eligible are agencies with three years' experience in the provision of community based social services to persons living with HIV/AIDS OR three years experience providing case management or community based social services to high risk populations, which includes one year of HIV related experience.

There are currently 50 approved Community Follow-Up Program providers: 38 in New York City, 5 in the Long Island/Westchester regions and 7 in upstate New York. As of December 31, 2007, the program has served more than 142,079 individuals and the active caseload was 14,306. The program continues to serve a predominately minority population, persons with mental illness, active substance users, and persons at advanced stages of illness. Of the total population actively served, 50% were African American, and 36% were of Hispanic origin. The program continues to be successful in targeting women and families. Fifty-five percent (55%) of the active caseload were women, many of whom had children. Case reviews and annual report information indicate that the program has produced positive outcomes for clients, including entrance into treatment, increased adherence with care regimens and increased use of services required for self sufficient functioning in community settings.

Case Management Training Initiative

The case management training initiative assists HIV service provider agencies, as well as other health and human service providers, throughout all of New York State, to ensure proper training of case management staff. Three Centers of Expertise in Case Management have been contracted to develop and deliver advanced curricula based on provider input. Training topics have included:

  • Psychosocial Issues for Women Living with HIV;
  • Case Management with Active Substance Users;
  • Case Management with Clients Involved in the Criminal Justice System;
  • Improving Documentation Skills for HIV Case Managers (available online) ;
  • Building Bridges to Cultural Competency;
  • Establishing Boundaries and Recognizing Countertransference;
  • Death, Dying & Bereavement;
  • Personal Safety;
  • Managing HIV as a Chronic Illness;
  • HIV Family Centered Case Management;
  • Supervision & Leadership for Case Management Programs;
  • Interdisciplinary Case Conferencing;
  • Advanced HIV Case Management Service Planning;
  • Ensuring Success: Navigating the Child Welfare System in HIV Case Management; and
  • Substance Use and HIV/AIDS: Improving Outcomes in Case Management.

NYSDOH, AIDS Institute Regional Training Centers also provide courses developed by the Centers of Expertise in Case Management including:

  • Introduction to Case Management (available online);
  • Enhancing the Partnership Between Client and Case Manager;
  • Serving Families: From Assessments to Service Plans;
  • Addressing Prevention in HIV Case Management;
  • Mental Health Services: Ensuring Appropriate Referrals for HIV Positive Clients; and
  • HIV Disclosure: Deciding Who and When to Tell.

By offering these trainings on a larger scale statewide, the AI is able to better accommodate the increased demand for training newly hired case management staff, while freeing up the Centers of Expertise to continue development and delivery of new training topics.

Case Management Outcomes and Performance Improvement Project

Since 1998, the Bureau of Community Support Services, with input and participation of Community Follow-up Program providers, has implemented and refined a system to measure case management client outcomes. For five years, the Bureau utilized external reviewers to measure indicators through retrospective chart review. A grass roots process was used to select indicators covering key categories important to case management clients (Optimal Health, Independent Living, Family Stability, Adult Education/Employment, Mental Health, Substance Use, Legal Services and Entitlements/ Benefits). Programs each received a report aggregating results from a sample of 25 client charts and comparing results with an aggregate of all other agencies in their geographic area.

Concurrent with this project, the Case Management Section began assisting programs to interpret and utilize outcomes and other data sources for program improvement. Workshops, conferences, and online resources in Quality Improvement theory and tools, using actual case management outcomes data as problem examples, were developed and provided to agency staff along with customized on-site workshops and consultation. Quality Improvement collaboratives, consisting of representatives from several case management programs, used Rapid Cycle methodology in order to address common program challenges identified through outcomes and monitoring data, such as improving progress notes and serving family members more effectively.

The Bureau of Community Support Services is now implementing a new stage of the outcomes project where case management programs will record standard core client medical, substance use, mental health, and housing outcomes into a universal reporting database. A goal of this project is to make reporting outcomes a routine part of the case management process, and to facilitate program access to their own outcomes data through a variety of reports for use in quality improvement efforts.

Standards

The AIDS Institute Case Management Standards Workgroup was convened to review overall case management service guidelines across all AIDS Institute's initiatives in order to update and streamline the case management process, encourage more efficient use of resources, and promote quality of case management services. During the process of review, AIDS Institute staff convened representatives from medical and psychosocial case management programs serving diverse populations in a variety of settings and geographic locations soliciting input and feedback on existing models of case management, and on problem areas. As a result of this process, universal standards were created that define case management, describe updated models of case management services, and clarify service expectations and program requirements. AIDS Institute Standards for HIV/AIDS Case Management are available online.

Funding

Medicaid reimbursement for the Community Follow-Up (COBRA) Program is based on an approved hourly rate and billed directly through the Medicaid Management Information System (MMIS). The approximate total Medicaid payment to CFP providers for 2004 was $60 million. Approximately $1.1 million in federal and State funds support contracts for case management services and for case management training/evaluation.

Contact:

Case Management Section
Bureau of Community Support Services
Division of HIV Health Care and Community Services
(518) 486-1323