Community Support Services

Case Management

Program Description

The Bureau of Community Support Services oversees the Medicaid and grant-funded case management program, 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.

HIV/AIDS case management intended outcomes include, but are not limited to:

  • Early access to and maintenance of comprehensive health care and social services;
  • Improved integration of services provided across a variety of settings;
  • Greater participation in and optimal use of the health and social service system;
  • Increased knowledge of HIV disease and delay of HIV progression;
  • Reinforcement of positive health behaviors; and
  • Personal empowerment and improved quality of life.

Comprehensive Medicaid Case Management (CMCM)

The Comprehensive Medicaid Case Management (CMCM) Program, also known as COBRA Case Management, was implemented in 1990 and 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 CMCM Program model utilizes a team of case managers and paraprofessionals to provide comprehensive and intensive case management services.

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: 5) provide access to services that foster independence and self-sufficiency; 1) ensure adherence to care and treatment; 2) prevent or delay institutionalization; 3) increase universal access to HIV-related services; and 4) promote early intervention.

There are currently 50 approved CMCM 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 serves 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% are African American, and 36% are of Hispanic origin. The program continues to be successful in targeting women and families. Fifty-five percent (55%) of the active caseload are women, many of whom have 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.

Grant-Funded Case Management

AIDS Institute grant funded case management activities are provided throughout New York State, and are available to persons living with HIV/AIDS (PLWH/A) in a variety of settings such as community health clinics, community based organizations, and AIDS service organizations. In addition to assisting PLWH/A to access and maintain medical and psychosocial services, case management activities may include negotiation and advocacy for supportive services, consultation with providers, navigation through the service system, psycho-social support, and general client education. The goal of case management is to promote and support independence and self-sufficiency. As such, the case management process requires active participation of the client in decision-making, and supports a client’s right to privacy, confidentiality, self-determination, dignity and respect. Services that are provided must be compassionate non-judgmental, culturally competent, and of high quality.

Case Management Training Initiative

The case management training initiative assists HIV service provider agencies, as well as other health and human service providers, throughout New York State to ensure the appropriate training of case management staff. Three Centers of Expertise in Case Management have been contracted to develop and deliver advanced curricula.

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 Counter-transference;
  • Death, Dying & Bereavement;
  • Personal Safety;
  • Managing HIV as a Chronic Illness;
  • HIV Family Centered Case Management;
  • Supervision and 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.

New York State Department of Health, 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 statewide, the AIDS Institute is able to accommodate the increased demand for training newly hired case management staff, enabling 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 the participation of CMCM providers, has implemented and refined a system to measure case management client outcomes. The Bureau utilized external reviewers to measure indicators through retrospective chart reviews. Indicators covering key categories important to case management clients were selected and programs received reports that compared their indicators with other agencies in their geographic area. Programs are assigned with interpretation and utilization of outcomes and other data sources for program improvement. Workshops, conferences, and online resources in Quality Improvement theory and tools, using case management outcomes data as examples, are 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 to address common program challenges identified through outcomes and monitoring data. The next phase of the outcomes project, case management programs recording standard core client medical, substance use, mental health, and housing outcomes into a universal reporting database is under way. This project will make reporting outcomes a routine part of the case management process, and will facilitate program access to their own outcome data through a variety of reports for use in quality improvement efforts.

Standards

Universal standards were developed through a collaborative process to 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.

Contact:

Tara Tate
Director, Bureau of Community Support Services
Division of HIV Health Care
(212) 417-4486/4490
txt02@health.state.ny.us

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Ryan White HIV Care Networks

Program Description

The AIDS Institute manages 11 regional/borough-wide HIV Care Networks (consortia) through Part B of the Ryan White HIV/AIDS Treatment Modernization Act of 2006. These Networks, located throughout New York State, are local associations of health care providers, community-based organizations, community leaders, and persons both infected and affected by HIV/AIDS.

The mission of the Networks is to promote a coordinated community response that results in improved access to care and supportive services for those infected with HIV/AIDS. The vision of the Networks is a comprehensive continuum of high quality services that is responsive to the needs of people infected with HIV/AIDS. The Networks undertake the mission through the following activities:

  • Promotion of a full complement of HIV/AIDS care and services through the establishment of an active, vibrant, participatory association of local and regional stakeholders that may include:
  • HIV/AIDS service providers;
  • People living with HIV/AIDS, their caregivers and loved ones;
  • Representatives of Ryan White Program (Parts A-F) and planning bodies in the region;
  • Local HIV/AIDS task forces;
  • Local and state government representatives;
  • Social services agencies (agencies serving special populations, related services);
  • Business associations;
  • Faith-based communities;
  • Community leaders, local associations and coalitions;
  • Representatives of individuals with HIV disease who formerly were prisoner; and
  • Other parties committed to making a fully functioning, quality HIV/AIDS service system.
  • Identification of populations and subpopulations of individuals and families with HIV disease, particularly those experiencing disparities in access and services.
  • Regular assessment of service needs to identify barriers to care and gaps in the service delivery system. Propose solutions to address barriers through the development and implementation of strategies that focus on coordination of community resources and/or the identification of new resources.
  • Identification of emerging issues, especially those with potential impact on the HIV/AIDS service system and the lives of those living with HIV/AIDS.
  • Development of a service plan, identifying populations and subpopulations of individuals and families with HIV disease and describing regional service needs, gaps and emerging issues.
  • Promotion of consumer involvement to enable HIV-infected individuals to participate in and inform HIV/AIDS policy and program development to assure that the needs of PLWH/A are addressed.
  • Educational and awareness activities for providers and consumers that result in an improved understanding of the HIV/AIDS service delivery system as well as advances in HIV/AIDS care and treatment. Inform legislative, government and community stakeholders at the local and state levels of regional needs related to HIV/AIDS and stimulate action to address those needs.
  • Clearinghouse for updated regional HIV/AIDS information, including information on available services, local epidemiology, and other data. Facilitate flow of information to service providers and other community members about the local impact of the epidemic and available resources.
  • Statewide Coordinated Statement of Need (SCSN): Provision of input to the Ryan White SCSN and participation in SCSN activities.
  • Collaboration with the AIDS Institute to meet common goals, disseminate information to the community, provide input and feedback from communities to the AIDS Institute, and incorporate AIDS Institute initiatives into Network activities.
  • Participation on the Statewide AIDS Services Delivery Consortium (SASDC), a statewide advisory body charged with consulting with the AIDS Institute on population and region specific issues related to HIV/AIDS care, identifying emerging needs and gaps, and making policy recommendations.

Networks operate under the auspices of Lead Agencies that are selected through a competitive
RFA process. Lead Agencies provide administrative and programmatic leadership, guidance to the Network.

The 11 Statewide HIV Care Networks funded by the AIDS Institute are:

  • Western New York (Niagara, Orleans, Genesee, Erie, Wyoming, Chautauqua, Cattaraugus, Allegany)
  • Finger Lakes (Monroe, Wayne, Ontario, Livingston, Yates, Seneca, Steuben, Schuyler, Chemung)
  • Central New York (St. Lawrence, Jefferson, Lewis, Herkimer, Oneida, Oswego, Onondaga, Cayuga, Cortland, Madison, Chenango, Broome, Tioga, Tompkins)
  • Northeastern New York (Franklin, Clinton, Essex, Hamilton, Warren, Fulton, Saratoga, Washington, Montgomery, Schenectady, Rensselaer, Schoharie, Albany, Greene, Columbia, Otsego, Delaware)
  • Hudson Valley (Sullivan, Ulster, Dutchess, Orange, Putnam, Rockland, Westchester)
  • Long Island (Nassau, Suffolk)
  • Manhattan
  • Brooklyn
  • Bronx
  • Queens
  • Staten Island

Contact:

Tara Tate
Director, Bureau of Community Support Services
Division of HIV Health Care
(212) 417-4486/4490
txt02@health.state.ny.us

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Mental Health Initiative

Program Description

Mental health and HIV/AIDS research reflects the complex relationship and need for coordinated care among multiple service delivery systems. Treatment of the triply diagnosed, or those struggling with HIV infection, mental illness and substance abuse, calls for coordination and integration of services.

Since 1999, the New York State Department of Health AIDS Institute (AI) has funded programs specifically designed to assess and treat mental health problems in persons with HIV/AIDS and ensure individuals’ access to a range of services that facilitate retention in mental health and primary care. The Bureau of Community Support Services oversees the Ryan White Part B Mental Health Initiative which includes statewide contracts for the provision of direct mental health services to persons living with HIV/AIDS, and training and technical assistance to enhance the effectiveness of professionals involved in the delivery of mental health services to persons with HIV/AIDS.

All AI-grant funded programs are expected to comply with AI Mental Health Standards of Care as developed by a statewide workgroup composed of AI staff and clinical experts in the fields of mental health, HIV and substance use. Two program models are funded: direct services and training and technical assistance.

Direct Services for Persons with HIV/AIDS

The goal is to assure that persons with HIV/AIDS have access to a range of services that facilitate retention in mental health and primary care and increase medical and psychiatric treatment adherence. The AI currently funds 20 programs to provide a continuum of mental health services to persons with HIV/AIDS who do not otherwise have access to such services. Multidisciplinary mental health treatment teams provide an integrated treatment program in which team members share responsibility for the individuals served, and treatment plans are the result of a collaborative effort between team members and clients. The range of treatment and services is comprehensive and flexible, with home visits and intensive care coordination provided as needed.

Mental health treatment programs are required to make the following services accessible:

  • Initial assessment/evaluation;
  • Treatment planning;
  • Crisis intervention;
  • Psychotherapy (individual, family or group);
  • Psychiatric services (psychiatric and medication evaluation; monitoring and follow-up);
  • Clinical supervision; and
  • Care coordination to support mental health and medical treatment retention.

The mental health treatment team model is intended to enhance communication of relevant clinical information among providers, help increase adherence to evidence-based care and reduce unnecessary hospital stays and emergency room visits. Effective mental health treatment should assist persons with HIV/AIDS to reduce symptom distress and increase independent functioning, improve performance, and gain access to and retention in health care and support services.

Training and Technical Assistance

The goal of these programs is to improve the medical outcomes of persons living with HIV/AIDS by increasing the number of health care providers who are educated and motivated to counsel, diagnose, treat and medically manage individuals with mental illness and HIV infection, through the delivery of an array of consultation and training interventions throughout the state. These activities include the provision of individual agency-specific psychiatric consultation, the establishment of training programs that respond to unique regional needs or changes in the mental health field; and the coordination of regional and statewide seminars for the community and mental health providers working with persons with HIV/AIDS.

The AI currently funds programs to provide the following services:

  • HIV Psychiatric Consultation responds to HIV/AIDS medical and psychiatric provider needs by ensuring that providers are able to offer services that at a minimum include: diagnostic assessment and treatment recommendations; medical evaluation (including drug interactions); clinical and psychiatric consultation, including child and adolescent psychiatry; and other technical assistance as needed.
  • Training and Professional Development in advanced mental health practice includes, but is not limited to: understanding medical issues impacting psychiatric disorders and the neurological aspects of HIV; ways to better engage clients in treatment; education and training on the care of the triply diagnosed client; advice on legal and ethical issues related to mental heath; science and evidence based best practices; methods to measure and evaluate client outcomes; and training for mental health workers and other professionals about specific HIV treatment and the benefits of staying connected to the health care system.
  • Community Psychoeducation includes consumer mental health forums; training for community providers on the unique service needs of persons with HIV/AIDS in need of mental health and substance use treatment; and education to reduce stigma and discrimination associated with both mental illness and HIV/AIDS.

Contact:

Heather A. Duell, L.M.S.W.
Director of Mental Health
Bureau of Community Support Services
Division of HIV Health Care
(518) 486-1323
had01@health.state.ny.us

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Nutrition Initiative

Program Description

Good nutrition is essential to the management of HIV infection. Persons living with HIV/AIDS (PLWH/A) have special dietary requirements that must be taken into consideration as they are prone to nutritional problems as a result of compromised immune systems, poor absorption of nutrients, and poor diets due to the symptoms of the disease and/or the side effects of treatment. Many of these problems can lead to malnutrition resulting in lengthy and costly hospitalizations. Food and nutrition services (well balanced safe meals, nutrition assessments, counseling, and education) and highly active antiretroviral therapy can prevent or lessen the effects of malnutrition related to HIV and HIV-related conditions. In addition, nutrient dense meals and food packages tailored to the specific needs of PLWH/A can assist in maximizing the benefits of any medical interventions or supportive care. Nutritious food profoundly affects the immune system, may delay disease progression, increases tolerance of medical treatments and can have a major impact on the quality of life.

The intent of the Nutrition Initiative is to support nutrition interventions that improve, maintain and/or delay the decline of PLWH/A health status, and assist them to remain in their communities. The goal is to provide clients with the knowledge and skills necessary to be able to purchase and prepare nutritious food and meals.

The AIDS Institute Nutrition Initiative includes the provision of nutrition services and food and meal components as follows:

Food and Meal Services

  • Home-Delivered Meals (hot and/or frozen) help to maintain or improve the health and well being of home restricted individuals with HIV/AIDS by providing high calorie, high protein, therapeutically tailored meals and snacks. For PLWH/A who lack the ability to shop for and prepare food, home-delivered meals fulfill a critical need, often allowing them to remain in the community longer.
  • Congregate Meals are served in community locations fostering access to health care, prevention, and supportive services, while meeting the nutritional needs of PLWH/A. Many individuals using the congregate meal programs are indigent, homeless, or in marginal housing which lack kitchen facilities and food preparation equipment.
  • Food Pantry Bags and Food Vouchers allow PLWH/A with limited financial resources access to nutritious food. In conjunction with nutrition services, PLWH/A are able to increase their levels of independence by preparing meals and making their own food choices.

Nutrition Services

Provided by nutrition professionals: Registered Dietitians (RD), New York State Certified Dietitian-Nutritionists (CDN), Registered Dietitian-Eligible (RDE) or nutrition students supervised by a RD or CDN; include:

  • Nutrition Assessments and Reassessments;
  • Nutritional Counseling;
  • Nutrition Group Education; and
  • Bioelectrical Impedance Analysis (BIA)

Contact:

Tara Tate
Director, Bureau of Community Support Services
Division of HIV Health Care
(212) 417-4486/4490
txt02@health.state.ny.us

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General Legal Services

Program Description

The General Legal Services initiative was established in 1990 to provide legal assistance for HIV– infected individuals. Legal assistance is provided for a wide variety of matters including consumer/finance, education, employment, health, housing, income maintenance, individual rights, and other miscellaneous benefits such as wills, health care proxies and advance directives. Many of the providers funded through this initiative have established pro bono networks which greatly expand access to legal services for those in need. This funding also provides training and technical assistance on HIV-related legal matters to staff and clients of health and human services agencies.

A total of six organizations are funded statewide through this initiative, one of which provides the technical assistance and training. The direct service organizations are located outside of New York City and cover the Buffalo, Rochester, Albany, Lower Hudson Valley and Long Island regions.

Contact:

Deborah Hanna
Program Coordinator, General Legal Services
Bureau of HIV Ambulatory Care Services
Division of HIV Health Care
(212) 417-4764
dlh02@health.state.ny.us

or

Felicia Schady
Director
Bureau of HIV Ambulatory Care Services
Division of HIV Health Care
(518) 473-8427
ffs01@health.state.ny.us

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Statewide AIDS Service Delivery Consortium (SASDC) for Special Populations

Program Description

The Statewide AIDS Service Delivery Consortium (SASDC) Advisory Group provides input and guidance to the AIDS Institute on a wide array of policy areas including the unique needs of six special populations who are underserved and require collaborative interventions. The six special populations are: 1) men of color who have sex with men; 2) mentally ill chemical abusers; 3) the homeless; 4) prison releasees, parolees and probationers; 5) immigrants and the undocumented; and 6) migrants and seasonal farm workers.

SASDC is a diverse statewide body comprised of individuals including health care providers, community based organizations, persons living with HIV/AIDS, and the network coordinators from each of the eleven Ryan White HIV Care Networks located in regions throughout the State. SASDC undertakes its responsibilities by:

  • serving as a forum to draw on the expertise, information, and experience of consumers, providers, and community members with the intent of identifying barriers and service needs of people living with HIV/AIDS;
  • identifying barriers to care faced by marginalized populations and helping to define the unique service needs of the HIV infected/affected population;
  • advising the AIDS Institute on matters pertaining to the Ryan White Part B program by identifying service needs and gaps for marginalized populations throughout New York State; and
  • advising and collaborating with the AIDS Institute on program design and targeted funding initiatives that meet service needs, and addressing barriers to care for underserved special populations.

Contact:

Wanda Jones-Robinson
Office of Planning and Policy
(212) 417-4507
wjr01@health.state.ny.us