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Rural Health Information Hub

Case Management and Patient Navigation

Case management and patient navigation programs help to meet the diverse needs of people who are living with HIV/AIDS in order to facilitate retention in care. When people have comorbid chronic health conditions or have unmet needs such as unstable housing or limited money for food, it can be extremely challenging to adhere to treatment.

The Ryan White program defines case management as

“a range of client-centered services that link clients with healthcare, psychosocial, and other services provided by trained professionals.”

The case manager may make referrals, coordinate care with providers and specialists, and manage the exchange of information between providers and human services organizations.

Similarly, HIV patient navigation includes a range of patient-centered services. Patient navigators work to connect individuals with healthcare services in a timely manner; improve access to medications, education, transportation, and counseling; and provide other case management support that can reduce barriers to care. Patient navigation services can be provided by nurses, community health workers, social workers, or other clinical or lay staff members. Peer navigator programs may perform similar functions to patient navigation, but the case manager or mentor is an HIV-positive, medication-adherent navigator. These initiatives have been particularly successful for some rural programs.

There are many promising examples of case managers and patient navigators using care coordination strategies to keep people engaged in HIV treatment in rural communities. Populations that may benefit from case management and patient navigation include individuals who were recently diagnosed with HIV, individuals at high risk for HIV, and individuals with suboptimal HIV/AIDS care outcomes. Information about other types of promising rural care coordination programs can be found in the Care Coordination Toolkit.

Ryan White grantees, like health departments, can apply to receive funding to implement case management services, which can then be tailored to meet the needs of the community. Ryan White medical case management activities must include several elements:

  • Needs assessment
  • Individualized care plan
  • Care coordination
  • Monitoring
  • Ability to reevaluate and change the plan as needed

These requirements must be followed for all types of case management, both in-person and virtual, in order to receive funding.

Examples of Rural Programs Using Case Management and Patient Navigation:

  • The Antiretroviral Treatment Access Study (ARTAS) describes an intervention that links recently diagnosed HIV-positive individuals with HIV care and works to keep them engaged in future care. Case managers work to build relationships with people living with HIV and focus on identifying strengths and skills to link them with goals for treatment. During meetings, case managers help people feel comfortable in different clinical care settings, empower people to seek out necessary medical care, connect them with available community social services, and advocate for other needs.
  • Colorado Health Network is a Colorado-based organization that supports thousands of people throughout the state and in rural communities who are living with HIV/AIDS. The organization uses case management and care coordination principles to treat medical, mental, and oral health needs and to connect people to other support services such as transportation, financial assistance, housing, and nutrition services.
  • Project CONNECT (Client-Oriented New Patient Navigation to Encourage Connection to Treatment) is an evidence-based intervention designed by researchers at the University of Alabama-Birmingham that can be implemented in HIV/AIDS clinics and is designed to help orient and educate people living with HIV about treatment within five days of an initial diagnosis. Newly diagnosed individuals work with a Project CONNECT facilitator to build rapport and receive referrals to substance use disorder treatment, mental health clinics, and for other health and social services as needed. Project CONNECT is included in the CDC Compendium of Evidence-Based Interventions and Best Practices.
  • The HIV Care Coordination Program (CCP) is another intervention included in the CDC's compendium that has been implemented in HIV clinics in order to integrate patient navigation services, home visits, medication adherence assistance, and clinical care coordination to improve retention in care. By including all of these components, the program aims to help newly diagnosed people with HIV better manage treatment through help with navigating the healthcare system and the overall treatment process.
  • Similarly, the Oregon HIV Care and Treatment Program is a region-based model supported through funding by the state health department and the Ryan White program. The program uses case management to help people access health and social services available for individuals living with HIV/AIDS. While the program is managed at the state level, it is implemented at a local and regional level, which facilitates individual attention to meet specific community needs. There are separate intake coordinators for initial screening, care coordinators who connect people to additional social services, and medical case managers who work with medical providers to connect people to treatment options. Each coordinator receives specific training and licensing relevant to his/her role.
  • Nebraska AIDS Project (NAP) provides case management, HIV testing, and prevention education to people who are newly diagnosed across Nebraska and throughout sections of Iowa. The NAP program consists of five sessions and focuses on HIV/AIDS education, medication treatment and drug side effects, the importance of lifestyle changes, confidentiality and support, navigation of the healthcare system, and self-management. A Linkage Coordinator collaborates with both clients and providers to help schedule appointments and HIV lab screenings, manage medications, and follow up on appointment attendance.
  • Rural AIDS Services Program (RASP) “creates a positive social impact through case management services by developing a partnership between the client and case manager to work together to maintain client independence and increase access to HIV medical care.” RASP services include coordinating care between medical and social services providers, connecting people with the Texas HIV Medication Program, and assisting with household expenses in order to alleviate the financial burden of HIV.
  • The Southeast Mississippi Rural Health Initiative has a Ryan White Program housed in their Hattiesburg Family Health Center. Within the center, a team of nurse case managers, social workers, and outreach workers are trained in delivering HIV treatment and work to ensure that people receive quality, confidential care. The center also offers free counseling and testing for high-risk individuals and provides HIV prevention education to the local community.
  • Hope and Help, of Central Florida, provides medical and non-medical case management, peer mentoring, and food pantry services to a medically underserved area of central Florida. Their clients may be assigned peer mentors and/or case managers to help improve medication adherence and increase access to services. Case managers also serve as patient advocates and care coordinators.
  • Matthew 25 AIDS Services works with the Kentucky HIV Care Coordination Program to “facilitate the provision of quality care and services to HIV infected individuals and their families in a timely and consistent manner across a continuum of care.” Matthew 25 also educates its clients on HIV transmission and positive health habits and assists people with accessing medical care. In addition, Matthew 25 helps people apply for Medicaid or Social Security Disability benefits and provides housing, legal, and nutrition services.

Resources to Learn More

Implementing a Community Engagement Program to Enhance Viral Suppression in Rural Populations
Slides from the 2020 National Ryan White Conference on HIV Care & Treatment discussing the barriers and facilitators that impact people living with HIV in rural communities. Identifies resources and strategies for implementing community engagement programs that include the utilization and training of community health workers (CHWs) to support viral suppression and care management of HIV.
Author(s): Rajabiun, S., & Williams, B.
Organization(s): TargetHIV, University of Massachusetts, Ryan White HIV/AIDS Program
Date: 8/2020

Peer Engagement to Improve Linkage to Care and Improve Retention for Youth, Women, Infants and Children
Slides from the 2020 National Ryan White Conference on HIV Care & Treatment discussing the involvement of peer support to improve the linkage and retention to care for youth, women, infants, and children. Describes how peers can help clients overcome barriers to care and identifies tools and activities used by peers to help maintain client engagement.
Author(s): Pleasant, R., Mendez, T.K., & Andrew, R.
Organization(s): TargetHIV, Bexar County Hospital District dba University Health System, Ryan White HIV/AIDS Program
Date: 8/2020

Ending AIDS through Jobs: Employing People with HIV as Peer Navigators and Community Health Workers
Slides from the 2020 National Ryan White Conference on HIV Care & Treatment highlighting proven methods using peer training and peer internship to improve psychosocial and health outcomes, and vocational development. Discusses the importance of employment and vocational training to lessen the viral load and stop the epidemic. Identifies best practices for incorporating peer navigators and community health workers (CHWs) into health and social service organizations.
Author(s): Duke, S.I., Fair, W., & McKinney-Prupis, E.
Organization(s): TargetHIV, Alliance for Positive Change, Ryan White HIV/AIDS Program
Date: 8/2020

Engaging Rural Populations in HIV Care and Treatment: Examples from the Deep South
Slides from the 2020 National Ryan White Conference on HIV Care & Treatment highlighting the importance of community engagement to improve access to HIV care, treatment, and adherence in rural areas. Discusses methods for identifying rural HIV populations, linking clinical services with social determinants of HIV screening, and describes the barriers and enablers for people with HIV in rural areas.
Author(s): Nunn, A., Tao, J., & Rajabiun, S.
Organization(s): TargetHIV, National Institutes of Allergy and Infectious Diseases, Ryan White HIV/AIDS Program
Date: 2020