4.2 Essential Components of a PCM Program

Each of the seven essential components of a PCM program are described in detail in the following sections.

4.2.1 Client Recruitment and Engagement

Each PCM program must have a comprehensive plan that contains explicit protocols to recruit and engage clients for PCM. Making a PCM program well-known and visible for those persons the program intends to serve is important. Recruitment strategies might include (1) enlisting the assistance of a street outreach program serving a similar target population to identify potential PCM clients; (2) recruiting recently identified HIV seropositive persons from a counseling and testing site or partner notification service; or (3) recruiting clients from other programs such as an STD clinic, a women's health clinic, or a drug treatment program. In some cases, programs have used various incentives (for example, bus tokens, hygiene kits, tee shirts, and so on) to enhance recruiting efforts [Purcell, DeGroff, Wolitski, Submitted for Publication].

Acting quickly and early in the PCM process is important. Research shows that effective outreach and intake efforts are associated with a quick response time and assertive follow-up, a fact that has important implications for successful client recruitment in case management (Rothman 1992). For example, to ensure initial engagement in PCM, a program may require staff to follow up with each client a minimum of three or four times within the first 30 days, two of which must be in person.

4.2.2 Screening and Assessment

To maximize staff resources, potential PCM clients must be initially screened to ensure their eligibility for the service. Screening may include assessing risk behavior, intention, or readiness to change risk behavior (Prochaska and DiClemente 1992; Ajzen and Fishbein 1980). Case managers should also assess, over the course of the first three to four PCM sessions, a client's willingness and ability to participate in HIV risk-reduction counseling. If a potential client is found ineligible for PCM services, counseling and referrals relevant to their needs must be provided.

The need for a thorough assessment of clients' HIV, STD, and substance abuse risks, along with their medical and psychosocial needs, is essential for PCM. Assessment should identify behavioral factors that increase the risk for infection or transmission of HIV and other STDs. Assessment should also include the determination of whether or not the client has been HIV antibody tested and the client's knowledge of his or her HIV serostatus. The case manager should engage the client in a discussion that enables the client to recognize and accept personal risk for HIV. A client-centered approach to assessment is essential - the approach should be thorough and individualized for each client. Case managers should develop effective interactive methods to involve the client in identifying risk behaviors.

To provide the case manager with a more complete understanding of each client's medical and psychosocial needs and the overall context in which HIV risk behavior occurs, the following items should be assessed: health; adherence to HIV-related treatment; STD history; substance and alcohol use; mental health; sexual history; social and environmental support; skills to reduce HIV risk; intentions and motivations; barriers to safer behaviors; protective factors, strengths, and competencies; and demographic information. When combined, assessment activities should yield a comprehensive picture of the client's HIV prevention needs (PROCEED, Inc. 1997).

Case managers must provide clients a copy of a voluntary informed consent document for signature at the time of assessment. This document must assure the client of confidentiality (See Section 6.0, Ethical and Legal Issues).

Potential areas for assessment include the following:

Health  This assessment should address access to medical care; current or chronic health conditions; HIV serostatus; date of last HIV antibody test; history of HIV-related opportunistic infections; date of last TB test; TB status; and, for women, date of last gynecological exam, birth control methods, and pregnancy history.

Adherence to HIV-Related Treatment  For persons living with HIV and receiving drug treatment, the assessment should address issues related to adherence to HIV-related treatment. Although new antiretroviral therapies have shown tremendous clinical benefit, ongoing concerns about adherence to complicated drug regimens and the likelihood of antiretroviral drug resistance are serious issues that must be actively addressed by prevention case managers. Areas for assessment within this category include adherence to antiretroviral therapies, adherence to treatments for opportunistic infections, barriers to adherence, factors facilitating adherence, and ability and intention to follow complex treatment regimens.

STD History  The prevention, diagnosis, and treatment of STDs other than HIV is an essential component of any PCM program. The sequelae of untreated STDs can be serious. Untreated chlamydia and gonorrhea are two major contributors to preventable tubal infertility. Furthermore, acute STDs, particularly those involving lesions on the skin or mucous membrane, facilitate the transmission of HIV. Therefore, clients' history and treatment of STDs should be assessed as well as the date of their last STD medical evaluation.

Substance and Alcohol  Use A number of factors related to substance and alcohol use should be assessed including the following: history of injecting drugs, alcohol use, and other non-injecting drug use; drug(s) of choice; frequency of use; route of administration; length of time using drugs/alcohol; frequency of needle sharing; treatment history; psychosocial context of drug/alcohol use; and affect of drug/alcohol use on sexual behavior. The potential relationship between substance use and unsafe sexual behaviors highlight the need for a comprehensive assessment of both injecting and non-injecting drugs.

Mental Health  Several factors related to mental health should be considered including the following: family and personal mental health history; history of treatment, therapy, and hospitalization; adherence to treatment; suicidal ideation and history; and psychotropic medication history.

Sexual History  A comprehensive sexual history is necessary to fully assess sexual risk behavior and related factors. Areas for assessment include number of sex partners; current partners (nature of relationships); HIV serostatus of partners; sexual behaviors practiced and frequency of behaviors; history of sexual abuse; role of alcohol and drugs during sex; involvement in sex in exchange for drugs/money/and so on; risk behaviors of partners; condom use, including barriers and facilitating factors for condom use; and knowledge of safer sex practices.

Social and Environmental Support  Assessing key factors related to social and environmental support will provide a prevention case manager a more comprehensive picture of the context within which a client engages in risk behavior and of external factors potentially influencing risk behavior. Areas for assessment include the following: living situation; economic status; sources of income; employment; in or out of school, if youth; emotional support sources; history of incarceration; significant others; and connections to the community, for example, friends, family, church, and service providers.

Skills to Reduce HIV Risk  Prevention case managers should assess the level of client skills in areas such as the following: use of condoms; sexual assertiveness; use of needle and syringe sterilization methods; use of safer injecting skills; and communication and negotiation skills.

Barriers to Safer Behavior  A careful assessment of clients' perceived barriers to safer behavior is essential. Potential barriers include the following: knowledge of risk associated with unprotected intercourse and using unclean shared filters, cookers, and rinse and diluent water; availability of, and willingness to use, condoms and sterile syringes and injection equipment; potential for violence; legal concerns; cognitive or perceptual barriers; and personal and/or cultural barriers - values and norms around sexuality, drug use, or gender roles that affect risk behavior.

Protective Factors, Strengths, and Competencies  Resources and factors that facilitate client's ability to stay healthy and practice safer behaviors should be assessed.

Demographic Information  Basic demographic information should be collected including age, gender, race/ethnicity, sexual orientation, and education.

4.2.3 Development of a Client-Centered Prevention Plan

A written client-centered Prevention Plan, based on information compiled from the assessment, must be developed. This plan should identify behavioral objectives to reduce the risk of acquiring or transmitting HIV that are time-phased, specific, and achievable. Both short- and long-term goals should be established by the client with the assistance of the case manager. Client participation is key because many clients are well aware of their goals and what would help them meet those goals (Rothman 1992). A client-centered approach will ensure that the Prevention Plan is responsive to the individual client's needs and circumstances. Therefore, prevention case managers should actively engage the client in setting behavioral objectives and identifying change strategies.

The Prevention Plan should identify effective change strategies that are reasonable and manageable for the client given his or her skills and circumstances. The Prevention Plan should specify who will be responsible for what and when (PROCEED, Inc. 1997). A high degree of specificity about the behaviors targeted for change, the interventions needed to implement change, and the expected outcomes should be included in the Prevention Plan.

For persons living with HIV and receiving medical treatments, secondary prevention interventions must focus on ensuring adherence to treatment for opportunistic infections and adherence to complex antiretroviral combination therapies. Secondary prevention interventions should also focus on maintaining the health of the client by ensuring the procurement of needed legal and entitlement services, treatment education, information on clinical care, and mental health services. The PCM Prevention Plan should detail the client's involvement, if eligible, in Ryan White CARE Act case management services along with other related programs or services. Further, the Prevention Plan should document efforts to ensure coordination and/or integration of PCM and Ryan White CARE Act case management.

The Prevention Plan must also outline efforts to ensure that a PCM client is medically evaluated for STDs at regular intervals regardless of symptom status. This will require that PCM programs establish a strong relationship and referral mechanism with local STD service providers. As noted earlier in this document, the sequelae of untreated STDs can be serious and include infertility.

For clients with substance abuse problems, the Prevention Plan must address referral to appropriate drug and/or alcohol treatment. This will require that PCM programs establish strong relationships with local substance abuse providers if these services are not provided in-house. As discussed earlier in this document, the relationship between substance use and unsafe sexual behavior highlights the importance for securing appropriate treatment for those who need it. Furthermore, a substance-abusing client benefiting from HIV risk-reduction counseling without having received substance abuse treatment is unlikely.

Finally, client files that include individual Prevention Plans must be maintained in a locked file cabinet to ensure confidentiality.

4.2.4 HIV Risk-Reduction Counseling

4.2.4.1 Client-Centered Counseling

Client-centered HIV risk-reduction counseling (that is, reducing the risk of acquiring or transmitting HIV) is the foundation of PCM. Client-centered counseling refers to counseling conducted in an interactive manner responsive to individual client needs (U.S. Department of Health and Human Services, May 1994). With a focus on meeting the identified behavioral objectives specified in the Prevention Plan, case managers must work with the client and apply a variety of strategies over multiple sessions to influence HIV risk behavior change. Depending on a client's readiness to change (Prochaska and DiClemente 1992), case managers should intervene to influence knowledge, perceived risk and vulnerability, intentions to change behavior, self-efficacy, skill levels, environmental barriers, relapse, and social support. Specific interventions for clients, regardless of HIV serostatus, may include skills building, individual counseling, couples counseling, crisis management, resource procurement, and preparation for referral of partners.

Counseling should be specifically tailored to the risk-reduction needs of each client. Table 1 summarizes factors that influence HIV risk behavior change (PROCEED, Inc. 1997 and Kelly 1992).

For persons of unknown HIV serostatus, interventions to prepare the client for HIV antibody testing may be appropriate. All clients must receive information regarding the potential benefits of knowing one's HIV serostatus. Counseling should explore barriers to testing faced by the client and seek to identify strategies to overcome these barriers. For individuals to make informed decisions about their health, early identification of HIV infection is important.

As part of client-centered counseling, PCM clients must be provided education about the increased risk of HIV transmission associated with other STDs and about the prevention of these other STDs. This counseling should also address the need for regular medical evaluation for STDs.

Finally, for seropositive clients, prevention case managers must discuss the notification of sex and needle-sharing partners who have been exposed to HIV. The purpose of notifying partners is to make them aware of their exposure to HIV and assist them in gaining access to counseling, testing, and other prevention and treatment services, including PCM, earlier in the course of infection (West and Stark 1997).

PCM program staff must develop a protocol for assisting seropositive clients in confidentially notifying partners and referring them to PCM and/or counseling and testing services. Two major approaches to partner notification have traditionally been applied by STD and HIV programs. Patient referral, when the patient or client notifies and refers his or her own sex and/or needle-sharing partners for testing, and provider referral, when health professionals, usually from the health department, notify the patient's partners of their exposure. Protocols for partner notification, within the context of PCM, should address the need for this service and be implemented at PCM enrollment or at any time clients potentially expose others while participating in the PCM program.

When clients choose to notify their own partners, prevention case managers should provide them with needed counseling, support, and skill building to ensure the successful confidential notification and referral of partners. Prevention case managers may invite clients to bring their partners to a PCM session, once notified, to provide partner counseling and ensure appropriate referrals to testing. Referral for medical evaluation and treatment of other STDs should be offered to all partners.

If the PCM client is unable or unwilling to notify partners himself/herself, the prevention case manager may facilitate notification by eliciting partner names and locating information and then, with the client's permission, requesting health department officials to confidentially notify partners. This approach requires that PCM programs establish an explicit relationship with health department officials to jointly carry out partner notification services. PCM program staff should be familiar with the health department's procedures for confidentially notifying partners and explain this process to clients. Finally, PCM programs may refer the client directly to the health department for assistance. Regardless of the approach used, partners identified may benefit from PCM services and should be assessed to determine their eligibility for the service.

Table 1. Factors That Influence HIV Risk Behavior Change

4.2.4.2 Partner Counseling

Including the client's partner in risk-reduction counseling sessions is appropriate within the context of PCM.

4.2.4.3 Secondary Prevention Counseling

Although PCM always involves primary prevention risk-reduction counseling, counseling related to secondary prevention for persons living with HIV is also appropriate within PCM. For instance, clients may need counseling support for accessing medical care and treatment. For persons receiving treatment for opportunistic infections and/or antiretroviral therapy(ies), counseling to support adherence to these treatments/therapies must be provided.
 

4.2.4.4 Substance Abuse and Mental Health Counseling

Although the emphasis of PCM is on HIV risk-reduction counseling, in some instances, some substance abuse and/or mental health counseling may need to be provided. In fact, counseling about strategies to avoid or modify substance abuse behaviors can be a form of HIV risk-reduction counseling. Such counseling should only be provided by staff skilled in these areas. Referring clients with these counseling needs to agencies with specific expertise in substance abuse and mental health counseling is optimal. However, if such services are unavailable and PCM staff have appropriate skills, short-term counseling focused on immediate living problems may be appropriate. Rothman (1992) found that counseling provided within case management is more effective when focused on information sharing, problem solving, reality testing, and socialization skills. PCM should not substitute for long-term therapy focused on long-standing personality issues or serious mental illness.

4.2.5 Coordination of Services with Active Follow-Up

The PCM program must establish a procedure for referring persons in a timely, efficient, and professional manner to sites providing services that may facilitate a client's ability to address and reduce his or her HIV risk behavior (for example, medical services, psychological treatment, substance abuse treatment, STD treatment, social services, and other HIV prevention services). Collaborative relationships should be established with appropriate representatives of referral sites. PCM staff should actively assist clients in securing services at referral sites. Such assistance may include accompanying a client to an appointment, providing transportation services or bus/rail tokens, ensuring the provision of child-care services, ensuring translation or interpretation services, and providing client skills-building to support his/her ability to effectively advocate on behalf of himself/herself with other providers.

Effective coordination of services necessitates that PCM programs have current, accurate community provider information on hand. This information should include hours of operation, addresses, phone numbers, accessibility to public transportation, eligibility requirements, and information regarding materials required at application such as bringing a driver's license, birth certificate, and so forth.

Most PCM clients may be already receiving services from other providers. Therefore, coordination of services also involves collaboration with an individual client's other case managers or counselors (for example, substance abuse counselor, Ryan White CARE Act case manager, probation officer, or housing or shelter supervisor). Such collaboration benefits the client and avoids duplication of services. Communication about an individual client with other providers is dependent upon the obtainment of written, informed consent from the client.

Finally, PCM program staff must have methods in place to follow up on referrals to assess the outcome, for example, whether or not the client received the needed service.

4.2.6 Monitoring and Reassessing Clients' Needs and Progress

Regular, structured meetings must be carried out between the prevention case manager and the client to assess the client's changing needs, monitor progress, and revise the Prevention Plan accordingly. In addition, HIV risk-reduction counseling must be provided at all appropriate opportunities. As mentioned previously, case managers should regularly inquire about recent sex and needle-sharing partners of seropositive clients.

If partners were potentially exposed to HIV, steps should be taken as outlined in Section 4.2.5 to inform them and encourage their participation in PCM and/or counseling and testing services. Assessment of progress in meeting the Prevention Plan objectives should be communicated to the client for review and discussion. Home visits, if appropriate, may provide a valuable opportunity for case managers to gain a comprehensive impression of the client's social and environmental support. Individual meetings with a client must be reflected in the client's progress notes.

As individual client's progress in a PCM program and psychosocial needs are met, their needs may become less acute. Piette et al. (1992) describes the use of "high-" and "low-need" client categories with separate protocols for frequency and type of interaction to manage caseloads. Assigning individual prevention case managers a balance of new PCM clients (presumably higher need) and continuing clients (lower need) may also reduce staff burn-out. Regardless of the staffing or triage system applied, monitoring ability is enhanced with a manageable caseload and adequate case records (Piette et al. 1992).

Retention of PCM clients is a concern (CDC 1997) [Purcell, DeGroff, Wolitski, Submitted for Publication]; therefore, program staff must define minimum levels of effort to reach clients for follow-up. For instance, a program should determine how many attempts - telephone calls, field visits, and so on - will be made before a client is made "inactive."

4.2.7 Discharge from PCM Upon

Attainment and Maintenance of Risk-Reduction Goals

In establishing a Prevention Plan, the prevention case manager and client will determine the appropriate time commitment for completing the plan. This will be based on client characteristics, needs, stated Prevention Plan objectives, and PCM activities provided.

PCM is a time-limited prevention activity intended to meet achievable behavioral objectives - identified by assessment and prevention planning - through counseling, service brokerage, and monitoring. PCM is not intended to substitute for extended social services or psychological care. Once the client has accomplished the behavioral objectives set forth in the Prevention Plan, a determination must be made by the client and prevention case manager that the client is ready for discharge (for example, a client is made "inactive" or "graduates," and PCM services are terminated). At the time of discharge, the prevention case manager, together with the client, should make every effort to ensure that the client is connected to needed resources and services.

In cases when the client has achieved his or her behavioral objectives, but actively experiences relapse to unsafe behaviors and faces on-going barriers to risk reduction, continuation of PCM services may be warranted. For these clients, PCM services may emphasize continued risk-reduction counseling.

Go to 4.3 Staff Qualifications