Medical Case Management

Providing Transition Assistance

The Minority AIDS Support Services, Inc. (MASS) Medical Case Management Program initiate services for eligible HIV/AIDS clients. This includes  inmates in jail prior to release, in an effort to promote access to HIV services for inmates who are not currently under care. This also enables us to facilitate continuum of care for those who are currently being treated.  Our staff offers a wide range of caring individuals consisting of Medical Social Workers, Social Work Case Managers, Nurse Case Managers, HIV Educators, Certified HIV Testers, and  Intake/Outreach Specialists.

Starting The Process

The Intake Specialists and Case Managers conduct intakes in the penal facilities weekly or as needed to provide medical case management pre-release services to inmates with HIV/AIDS that have six (6) months or less time to serve. Services are covered for 6 weeks post-release. MASS staff provides services seven (7) days a week, 24-hours a day for emergency or crisis intervention.

Upon admission to the program, eligible inmates are given the agency and the Case Manager’s telephone numbers. The clients are given instructions on how to reach the Case Managers and the agency prior to their release from jail. After release, follow-up visits are scheduled with clients in the agency to continue post-release medical case management services.

Services offered

MASS Medical Case Management services include intake to services, individual needs assessments, development of  comprehensive service plans, and the coordination of services required to implement the plan. Our case management offers coordination of post discharge care with correctional facilities, the provision of treatment adherence to HIV/AIDS treatments, and evaluating and updating of service plans as needed.  We monitor clients to assess the efficiency of the plan, periodic re-evaluation and adaptation of the plan as necessary over the life of the client.

Medical Case Management provides the case manager the opportunity to establish a rapport with the client, perform comprehensive assessments, and arrange appropriate referrals that will improve system level outcomes.

Individualized Client Assistance During Their Transitional Phase by:
  1. providing assurance of having and keeping their medical and follow-up appointments
  1. providing assistance with housing and food
  1. providing assistance in applying for funding and/or employment
  1. providing assistance in acquiring transportation
  1. empowering the client to become independent
Ryan White Part A Policies and Procedure Standards for All Providers Include a:
  1. Quality Management Policy
  1. Billing Policy (stipulates that Ryan White is the payer of last resort and no Service Fees charged for RW funded services for persons earning an amount equal to or less than 300% of the Poverty Guidelines)
  1. Client Acknowledgement of Services and Continuum of Care (explained and documented in plain language specific to the client and cultural sensitivity)
  1. Referral Policy
  1. Patient Rights (includes cultural sensitivity to all populations regardless race, gender, ethnicity, etc.)
What We've Accomplished

MASS Medical Case Management staff have screened over 500 inmates for eligibility of services and have admitted over 250 inmates to the program.  The program has improved system level outcomes. Ninety-five percent (95%) of the clients adhere to the medical and social service appointments scheduled for them by our Case Managers. However, housing for this population remains a problem. Homelessness has been identified as a major barrier for inmates with HIV/AIDS post release. Forty-three percent (43%) of the inmates serviced in our program this year were homeless at the time of incarceration.

MASS implemented HIV testing and a group level intervention in the Hampton Roads Regional Jail (HRRJ), Hampton and Newport News City Jails, Chesapeake City Jails and several community fairs for National HIV/AIDS Days during the year.  MASS has provided HIV testing and prevention services to over 1000 inmates and clients in the communities high-risk for HIV/AIDS.

Establishing Stability

MASS has also improved system level outcomes by implementing the MASS Transitional Housing Program to retain ex-offenders in care. This program has allowed MASS to facilitate re-entry of over 40 inmates into the community and helped them remain in care. This intensive case management service identifies HIIV/AIDS inmates prior to release from jail for eligibility of services. Eligible clients include newly diagnosed and /or homeless HIV positive inmates, frequent incarcerations, and substance abuse problems.

Since 2006, MASS has been collaborating with a minority Realtor in the community to provide Emergency/Transitional housing for our homeless HIV/AIDS clients. Other community landlords and organizations willing to house HIV/AIDS ex-offenders are continuously being sought. The homeless problem creates challenges for the Case Managers. The inconsistency in the time of day for releasing the inmates make housing placement for some inmates very difficult. Without a system in place for immediate assistance with their housing issues, some of the clients will not likely follow-up for care.

Many clients will be lost to follow-up. MASS coordinates the Emergency/Transitional Housing services for homeless HIV/AIDS inmates with HOPWA (Housing of People Living with HIV/AIDS) agencies in the TGA for available temporary and/or permanent placement services. Last year MASS used funds from our fundraising projects to assist with housing placement for some of our clients. However, since July 2010, our fundraising efforts have been very unsuccessful due to the poor economy. This is very disappointing for our organization.  Our data shows that inmates who are released with adequate housing will remain in care and out of jail much longer then when released to a homeless situation.

Job Placement

Along with the housing assistance for eligible clients, MASS has collaborated with community organizations and businesses to provide job placement opportunities for eligible clients. We have commitments from three local businesses (in Hampton, Newport News and Smithfield) to hire our eligible inmates for available jobs. For our clients who have found jobs, system level outcomes have improved by reducing homelessness, poor nutrition and weight loss, missed appointments and increased adherence to medication plans.

The case managers follow these clients closely with appropriate referrals and daily contact to start out and tapering off over time as a consequence of increased adoption of positive care behaviors. Eligible clients can remain in this  program up to six (6) months. There is a significant increase in keeping medical appointments and adherence to medications for clients enrolled in this program.

Linkage agreements have been established with key points of entry into the HIV Care System providers. They include Hampton Roads Regional Jail, Hampton Jail, ACCESS, PICH, Norfolk Community Health Center, C3ID/EVMS, IBWC, TACT, and Department of Probation and Parole. Our organization also has a long term relationship with Hampton and Newport News Community Services Board and Hampton Public Defenders Office for client referrals and coordination of services.