Country Doctor Community Health Center’s HIV Medical Case Management Program

Grantee: Country Doctor Community Health Centers
Timeframe: July 2017 – June 2020 | Total Amount: $509,995

Year 1: July 2017 – June 2018. Amount: $170,000
Year 2: July 2018 – June 2019. Amount: $170,000
Year 3: July 2019 – June 2020. Amount: $169,995

Country Doctor Community Health Centers (CDCHC) provides Medical Case Management (MCM) services to support high risk People Living with HIV/AIDS (PLWHA) engage in primary care, giving them access to critical medications and adherence education to help comply with complex medication regimens. Because the healthcare disparities among CDCHC PLWHA create significant barriers to successfully managing HIV/AIDS, CDCHC created an HIV Support Team comprised of three MCM and two nurses. This team complements the medical care provided by CDCHC’s clinical team.

CDCHC will use PHPDA funds to continue to provide on-site MCM services. MCMs offer a range of client-centered services that link PLWHA with health care, dental care, psycho-social, and other services provided by trained professionals within CDCHC and outside resources. On-site HIV clinical care coordination assures that CDCHC’s PLWHA have timely and coordinated access to all necessary services, while minimizing barriers to primary care. MCMs each work with the patient and other key family members to provide an on-going assessment of the clients’ needs and personal support systems.

MCMs help patients develop a plan to ensure readiness for, and remaining adherent to, their medication regimens. These plans are updated as treatment changes and/or compliance challenges require. Information packets on adherence include articles on the importance of adherence and its impact on health outcomes, graphs that illustrate that impact, pictures of the medications with written dosing for each drug, explanations of viral load tests and viral levels, and the importance of taking pills exactly as prescribed. These materials are reviewed with each patient.

Specific activities include:

• Initial assessment of service needs
• Development of a comprehensive, individualized care plan
• Coordination of services required to implement the care plan
• Continuous client monitoring to assess the efficacy of the care plan
• Periodic re-evaluation and adaptation of the care plan