2. Outcome 1: Clients access Medical Case Management Services  Objective 1: XX clients attend XXX face- to-face MCM office sessions.  Objective 2: XX clients receive XX face- to-face MCM home visits.  Objective 3: XX clients receive XXX MCM telephone/text/email contacts.  Objective 4: XX clients have XX face-to- face MCM sessions in locations other than those specified above. Outcome 2: Clients improve their engagement to medical care  Objective 1: XX clients attend XX medical appointments.  Objective 2: XX clients attend at least XX medical appointments within X months.  Objective 3: Case managers accompany at least XX clients to at least XX medical appointments.  Objective 4: Case managers conduct at least XX case conferences with primary care physicians and/or other services provides regarding treatment and care for at least XX clients. Outcome 3: Clients increase their ability for self-care and disease management Objective 1: XX clients complete a service plan. Objective 2: XX clients receive at least XX medication adherence sessions. Objective 3: XX clients receive at least XXX referrals to additional supportive services. Objective 4: XX clients receive a face-to-face service discharge session.

3. Service TypeService UnitNumber of Clients Face to Face Office VisitXX Face to Face Medical Accompaniment XX Face to Face Home VisitXX Face to Face DischargeXX Face to Face CM Care Conference XX Telephone/Text/Email ContactXX Face to Face Other VisitXX Care Coordination with PCPXX Other Type of Contact/Referral XX

4.  Quarterly Reports  Client Satisfaction Surveys  QM plan  Performance Measures  Meeting Attendance

5.  Deadlines:  Part A: 10 th of June, September, December, March  Part B: 10 th of July, October, January, April  Send report electronically to:  Part A: Michael Grego (mgrego@aidschicago.org)  Part B: Bashirat Osunmakinde (bosunmakinde@aidschicago.org)  Types of questions:  Report on scopes of service  Program progress  Barriers/Trends to service provision  Staffing changes  QI activities  Program income/client charges

6. Client Satisfaction Surveys  Sent out annually through web link and paper format  Completed surveys must be returned to AFC within 30-45 days  AFC will tabulate results and will provide detailed summary to providers QM Plan  Required annually  QI initiatives required for each funded service category

7. HIV Medical Visit FrequencyGap In HIV Medical VisitsCare Plan Percentage of case managed clients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. Percentage of case management clients, regardless of age, with a diagnosis of HIV who did not have a medical visit in the last 6 months of the measurement year. Percentage of case management clients, regardless of age, with a diagnosis of HIV who had a medical case management care plan developed and/or updated two or more times in the measurement year.

8.  CDPH Standards of Care exist for each service category funded by Part A  Medical Case Management  Non-Medical Case Management  Transportation  Emergency Financial and Housing Assistance  These standards will be made available to all agencies and should be used as a guide

9.  Contract Administrator’s Meetings  Large Case Management Meeting  Supervisor’s Meeting  12 Case Manager Trainings  Self care/burn out  Cultural competency

11. 11 Referrals  All referrals into case management are directed to AFC.

12. Referrals There are many sources AFC receives referrals (mostly via telephone), including: direct phone call to AFC, primary care provider, case management agency, or testing and counseling site. If the case management agency receives the client directly (i.e. walk-in), AFC’s Intake and Referral Managers must be contacted by phone prior to intake to ensure that the client is not already receiving services from another agency 12

13. Screening PROCEDURE: - The client will then be screened for the need for services (medical care and medication adherence, mental health, substance abuse, income, housing, etc.) - Demographic information will be gathered to help determine the appropriate agency (usually by zip code). *If the client is only in need of dental, legal, and/or food they will be referred to a Certification Specialist at AFC. 13

14. Assignment Cases are assigned to:  Part A-Funding allocated through the Chicago Department of Public Health (CDPH) using the Provide Database system. Part A assignments are enrolled as either medical or supportive referrals.  Part B- Funding allocated through the Illinois Department of health (IDPH) using the Provide Database System. Part B assignments are all considered to be medical referrals.  DRS- Funding allocated through Illinois Department of Human services using the VCM Database system. (**AFC do not enter clients in VCM-only the AAU can enter clients in VCM). 14

15.  Part A: Medical-60 clients  Part A: Supportive- 100 clients  Part B: Medical-60 clients  DRS: 45 clients *Ryan White case managers who have gone through the DRS training are able to take 5 DRS cases. 15

16.  Referrals are distributed based on where the client is currently residing, receives medical care, or individual preference.  AFC has 1-7 business days to refer a client, depending on client need.  Once AFC determines the agency where the client will receive services the Intake Referral Managers will fax over the referral or email it in an encrypted message to the CM and/or CM supervisor and email them once the fax was sent.  Once the CM receives the referral, the CM has 72 hours to contact the client. 16

18.  AFC does not facilitate any transfers. Transfers happen from one case manager to another. 18

19.  Ambulatory Outpatient  Mental Health  Psychosocial  Substance Abuse  Oral Health  Housing  Food Bank  Legal  Copayments and Out of Pocket Costs  MAP/PAP

21.  Face-to-Face Office Visits: Encounter between client and CM in CM’s office  Face-to-Face Medical Accompaniment: CM accompaniment of client to medical visit  Face-to-Face Home Visit: Encounter between client and CM in client’s home  Face-to-Face Discharge: Closure of clients  Face-to-Face CM Care Conference: Encounter between CM and providers involved in client’s care  Telephone/Text/Email Contact: Non face-to-face contacts between CM and client  Face-to-Face Other Visits: Encounter between client and CM at alternate designated location  Case Coordination with PCP: Encounter with client’s PCP to discuss client’s care  Other Type of Contact/Referral: Internal or external referral provided to client

23.  Scan in AFC medical form  Document conversation within a progress log

28.  Annual site visit to:  Review organizational policy and procedures  Provide feedback on case management performance  Review fiscal policy and procedures  Each agency will be provided with the following documents 30 days in advance:  Universal Tool  Fiscal Tool  Chart Review Tool  List of clients that will be audited  Overview of Site Visit  Introduction and overview of site visit expectations  AFC review of policies and procedures  Exit Interview

29.  CDPH Proposed Model  Medical vs. Non-Medical  Further discussion is occurring between AFC and CDPH as well as through input from the Leadership Collaborative Leadership Council

30. Ryan White funded Medical Providers Non-Ryan White funded Medical Providers Early Interventio n Services Part A Outreach Workers: Haymarket, SSHARC, U of C Non-Medical Case Management CDPH Bridge Project Medical Case Management CM Activities: focus on medication and appointment adherence and support services coordination New Case Management Model