Ryan White HIV/AIDS Program

Medical Case Management

The provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. In addition to providing the medically oriented services above, Medical Case Management may also provide benefits counseling by assisting eligible clients in obtaining access to other public and private programs for which they may be eligible (e.g., Medicaid, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, other state or local health care and supportive services, and insurance plans through the health insurance Marketplaces/Exchanges).

Referral for Health Care and Support Services

Referral for Health Care and Support Services directs a client to needed core medical or support services in person or through telephone, written, or other type of communication. Activities provided under this service category may include referrals to assist HRSA RWHAP-eligible clients to obtain access to other public and private programs for which they may be eligible (e.g., Medicaid, Medicare Part D, State Pharmacy Assistance Programs, Pharmaceutical Manufacturer’s Patient Assistance Programs, and other state or local health care and supportive services, or health insurance Marketplace plans).

Service Providers

Substance Abuse Outpatient Care is the provision of outpatient services for the treatment of drug or alcohol use disorders. Services include:

• Screening
• Assessment
• Diagnosis
• Treatment of substance use disorder
• Pretreatment/recovery readiness programs
• Harm reduction
• Behavioral health counseling associated with substance use disorder
• Outpatient drug-free treatment and counseling
• Medication assisted therapy
• Neuro-psychiatric pharmaceuticals
• Relapse prevention
• Residential

Service Providers

Mental Health Services are the provision of outpatient psychological and psychiatric screening, assessment, diagnosis, treatment, and counseling services offered to clients living with HIV. Services are based on a treatment plan, conducted in an outpatient group or individual session, and provided by a mental health professional licensed or authorized within the state to render such services. Such professionals typically include psychiatrists, psychologists, and licensed clinical social workers.

Service Providers

Outpatient/Ambulatory Health Services are diagnostic and therapeutic services provided directly to a client by a licensed healthcare provider in an outpatient medical setting. Outpatient medical settings include clinics, medical offices, and mobile vans where clients do not stay overnight. Emergency room or urgent care services are not considered outpatient settings.

Service Providers

Ending the HIV Epidemic (EHE) funded Psychosocial Support Services provide Peer Mentoring/Supportive Counseling and Peer Mentor facilitated HIV support and educational groups. Peer Mentors serve as a bridge between Clients and providers by reinforcing treatment adherence, supporting engagement and retention in HIV medical care, helping Clients navigate services, and assisting Clients in developing self-management skills.

Service Providers

Oral Health Care activities include outpatient diagnosis, prevention, and therapy provided by dental health care professionals, including general dental practitioners, dental specialists, dental hygienists, and licensed dental assistants.

Service Providers

Medical Nutrition Therapy includes:

• Nutrition assessment and screening
• Dietary/nutritional evaluation
• Food and/or nutritional supplements per medical provider’s recommendation
• Nutrition education and/or counseling

Ending the HIV Epidemic (EHE) funded Early intervention Services (EIS) provide timely linkage and re-engagement in HIV medical care and address barriers that may interfere with a client’s ability to initiate, resume, or remain engaged in care. EIS is coordinated with the local HIV Care Network including Ryan White HIV/AIDS Program Part A, Ending the HIV Epidemic (EHE), and Housing Opportunities for Persons with AIDS (HOPWA), and can provide services at or in coordination with key points of entry, including correctional settings. EIS prioritizes newly diagnosed individuals and individuals who have not established or maintained HIV medical care.

Service Providers

Housing assistance is provided through the Housing Opportunity for People Living with AIDS (HOPWA). The HOPWA Program helps increase housing stability, reduce risk of homelessness and increase access to care for people with HIV who have an income at or below 80% of area median income. Services include:

• Housing Case Management
• Short-Term Rent, Mortgage, Utilities (STRMU)
• Permanent Housing Placement (PHP)
• Tenant-Based Rental Assistance (TBRA)
• Short-Term Housing
• Facility Based Housing

Please visit HOPWA page for more information.

Service Providers

Medical Transportation services are available to Ryan White Eligible Clients and can be obtained through Case Management. Clients must be enrolled in Ryan White services, and not eligible for Medicaid, Medicare, or Advantage Transportation. Clients who meet the eligibility criteria may be eligible for a 30 day buss pass, 1 day buss pass, or door-to-door transportation. Eligibility for the 30 day buss pass and a 1 day buss pass depends on the number of service appointments a Client has within a 30 day period. For door-to-door transportation a Client must be farther than ¾ mile from a bus route and/or not physically able to use a bus.