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
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.
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
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
- 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
Examples of Rural Programs Using Case Management and Patient Navigation:
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.
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.
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. Different state health departments,
such as Indiana, have chosen to implement CCP to improve
retention in care.
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
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
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
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
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
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
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