What is case management?

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

On this page

How can case manager help?

Case managers can:

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

How do we work?

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

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.

What services are available?

The eligibility requirements for our clients differ according to where they live, via their local health district (LHD). This allows us to provide case management to people with HIV who live in low support areas.

  • Primary case management offered in: Far West, Murrumbidgee, Southern NSW and Western NSW LHDs.
  • Co-case management offered in: Central Coast, Hunter New England, Illawarra Shoalhaven, Mid North Coast, Northern NSW, Northern Sydney, Nepean Blue Mountains, South Eastern Sydney, South Western Sydney, Sydney and Western Sydney LHDs.

View map of LHDs

Primary case management eligibility criteria

To be eligible the individual needs to:

  • live in or receives health care in Murrumbidgee, Southern NSW, Far West or Western NSW LHDs
  • have co-morbidities and complex psychosocial issues.

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, their carer and local services. These will be reviewed every 3 months to determine if support is still required.

Co-case management eligibility criteria

To be eligible the individual needs to:

  • live in or receives health care in: Central Coast, Hunter New England, Illawarra Shoalhaven, Mid North Coast, Northern NSW, Northern Sydney, Nepean Blue Mountains, South Eastern Sydney, South Western Sydney, Sydney and Western Sydney LHDs
  • 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.

Notes for referrers:

  • Adahps will co-case manage with LHD staff.
  • Referrals from SESLHD, SLHD, SWSLHD must be made by a local HIV 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 with the client and their carer and reviewed every 3 months to determine if our support is still required.

Accessing a case manager

Staff from the following services may be able to link you a case manager in your area:


Current as at: Monday 20 June 2022
Contact page owner: Centre for Population Health