What is case management?

Our case managers follow the core elements of case management which include assessment, case planning, implementation (service delivery), monitoring and review. They begin by identifying what's needed to improve our client's health, situation or quality of life and then coordinating the support that's needed. Our clients, their carers and support services are involved in the care planning process.

On this page

How do case managers help?

  • advocate for you
  • organise your medications and reminders
  • arrange tests to monitor your memory loss or poor concentration
  • support you with housing issues
  • co-ordinate case conferences to identify your needs and monitor effectiveness
  • link you with social and support agencies
  • help you manage your medical appointments
  • arrange in-home and community support

How does co-case management work?

To provide support across the state we use a co-case management approach, that means we work with a case manager from another service, in the client's local health district. Our experience shows that when clients have challenging health needs both the clients and services benefit from a joint management approach.

When an individual doesn't have access to case management e.g. in some rural areas, we can be the primary case manager. In other areas where support is available, we co-case manage clients with moderate to severe HIV-associated cognitive impairment. This involves working together with the local health district to provide expertise in HIV cognitive impairment and to share the workload.

This co-case management model requires each client to have a primary case manager in their local area with the Adahps case manager taking on a support role.

Accessing a case manager

A number of people in NSW may be able to assist you to find a local case manager, including:

  • your GP
  • hospital staff
  • sexual health clinic staff
  • ACON
  • Positive Life
  • Bobby Goldsmith Foundation
  • Alzheimer’s Australia (NSW)
  • Multicultural HIV and Hepatitis Service.

Who is eligible for Adahps?

The eligibility requirements for our clients differ according to their local health district. From February 2019, we are testing a model of care which expands the eligibility criteria for individuals in low support areas to improve their access to case management support.

Co-case management is available in the following local health districts: Centr​al Coast LHD, Hunter New England LHD, ​Illawarra Shoalhaven LHD, Mid North Coast LHD, Northern NSW LHD, Northern Sydney LHD, Nepean Blue Mountains LHD, South Eastern Sydney LHD, South Western Sydney LH​D, Sydney LHD and Western Sydney LHD.

To be eligible the individual needs to:

  • have moderate to severe HAND (HIV-associated neurocognitive disorder) or other HIV-related cognitive impairment (such as PML or Cerebral Toxoplasmosis), with significant functional impact
  • live in or receive health care in NSW

Notes for referrers

  • Adahps will co-case manage with LHD staff.
  • Referrals from SESLHD, ISLHD, SLHD, SWSLHD must be made by a local case management service to ensure a co-case manager is involved. We will continue to accept referrals from the consultants to the service and The Panel for People with HIV Infection Who Risk Infecting Others, and will work with the LHD to secure a local case manager.
  • Clients can be referred or re-referred to Adahps at any time.
  • The level of cognitive impairment will be determined by a neuropsychological assessment.
  • The individual's functional deficit will be used to identify the type and extent of support needed and to clarify Adahps' role. Our case managers will determine functional impairment; with WHODAS 2.0, by proxy.
  • Adahps' role and that of other support workers will be clearly identified in a care plan. Care plans will be developed by Adahps and reviewed every 3 months to determine if our support is still required.

Primary case management

Case management is available in Far West LHD, Murrumbidgee LHD, Southern NSW LHD and Western NSW LHD.

To be eligible the individual needs to have:

  • HIV
  • co-morbidities
  • complex psychosocial issues
  • residence in or receive health care in NSW

Notes for referrers

  • To support rural areas with limited HIV support services Adahps can be the primary case manager (no local co-case manager is required).
  • Anyone can refer an individual.
  • Adahps role and that of other support workers will be clearly identified in a care plan, including anticipated timelines. Care plans will be developed by Adahps with the client and local services. These will be reviewed every 3 months to determine if support is still required.
  • We will test this model of care until February 2020.​
Page Updated: Tuesday 16 June 2020
Contact page owner: Centre for Population Health