East Bay HIV/STI Case Management Manual

Author: Georgia Schreiber

Introduction

As a case manager, helping clients locate and connect to a variety of services may be part of your job, because clients may have priorities other than seeking HIV care. To boost the success of your client in one area, it may be necessary to help them in others. 

Clients may have many reasons for not engaging in HIV care. For example, they may be asymptomatic and feel healthy. They may not have access to transportation. They may have more pressing concerns, like living in a tent and fearing their belongings will be stolen if they leave for an appointment. If your client has challenges or priorities other than engaging in HIV care and taking HIV medication, you may have success connecting them with care only after you help them address their housing, food, legal, and other health issues. In the process of addressing some of these barriers to care, you may build critical trust between yourself and your client that will eventually facilitate HIV linkage.

To address barriers to care, start by assessing the components of the client’s life, including family, people they rely on and people who rely on them, their occupation and housing status, and any issues with basic functioning such as mental health, substance use, stigma, source of income, or legal challenges. This process will help to construct a basic list of the client’s individual strengths and challenges before identifying resources and linking to services.

In most communities, accessing various social services and navigating government bureaucracies is challenging for anybody. For people who are overwhelmed with multiple problem areas and who may not have the knowledge and time to prioritize and advocate for themselves, you can be a crucial ally by working through the local system on their behalf. 

Every client is different, but you can develop a list of common needs that many clients have presented with. To save time and be more effective in helping clients, you can develop your own list of types of services, with names of organizations that provide them, ideally with contact information and the process for getting services. (In this manual, see the Referral List in the appendices section.) If time and experience permit, you can also make professional connections with specific people at as many of these partner organizations as possible. This way, when you are helping a client deal with an issue outside of your own specialty, you can introduce them to your contacts and create a “warm handoff” referral.

This section below highlights the keys to making successful referrals. 

What makes a strong referral?

A strong referral is one that addresses the specific needs of each client. For example, if you know your client would benefit from a lot of hands-on help, an ideal referral would be to a provider’s office with case managers who can give personal attention and assistance.

A strong referral would include the following elements: 

• The organization addresses the client’s area of need, e.g., housing or food.
• The site has features that make the client feel comfortable and more likely to follow through with tasks and appointments there, e.g., it is physically accessible, provides services and materials in your client’s preferred language, and offers the level of personal attention your client requires.
• The organization has the capacity to serve your client’s needs.
• The organization has responsive staff who can show ongoing dedication to the client after the referral has been made.

Networking with other service providers

The deeper a network you can develop among local organizations where you regularly refer clients, the better quality your referrals will be. You can get better service yourself with a friendly colleague, and together you serve the client better. Also, with a friendly colleague, you may get updates about the organization and any opportunities or barriers your client may face when dealing with it. You can build provider networks through introductions from colleagues, through cold calling and introducing yourself and your services, or by arranging a meeting with staff who would take a referral from you, such as a case manager. 

Developing a contact list and keeping it up to date

Once you build a list of organizations, update it regularly to keep up with staffing and organizational changes. 

Staying in contact with clients throughout the referral process

Before you give a client a phone number, an address, or even the name of an organization where you want to refer them, make sure the place is still in operation and that they have the capacity to take your client’s case.

Some clients can take the name of an organization and a phone number or address, and will outreach to that place themselves. Some clients prefer this approach. If you are confident the client will follow through with their own referral, just make sure the referral information is up to date before sharing it with them.

Other clients may need your help calling to make the first contact, setting up the appointment, or accompanying them to at least one appointment. Depending on your capacity, providing an individualized level of intervention and hands-on assistance will make a difference in the success of the referral and your client’s outcomes.

Beginning, middle, and end of the referral process

• Identify specific, detailed needs of your client.
• Talk with your client and assess their readiness and willingness to take a referral. Get their input and buy-in to receive a referral to an organization you have in mind.
• Make contact with the organization and make sure they have the capacity to take your client’s case.
• If possible, identify a person at the organization who will agree to work with you and your client and will warmly receive your client at the outset.
• Talk with your client about what they can expect from the organization, why they are going there, who they will be dealing with, and what paperwork they will need for their first contact with the organization.
• Help the client set up the initial appointment and gather paperwork, if necessary.
• Make sure the client has a plan for how and when they will get to the appointment.
• If needed, partner with the client through transportation and first appointment.
• Suggest that your client let you know how the appointment went or whether anything prevented the appointment from happening.
• Plan a time to check in with your client and the receiving organization after the first appointment, to make sure the connection happened and learn what next steps are needed, so you can help your client stay linked to the organization and succeed with their goals there.

Maintaining contact with other provider in the referral process and seeking feedback

If you already have a professional and or friendly rapport with a contact at the receiving organization, the follow-up process will be easier. When you first alert the contact about the referral, you can let them know you will be in touch to find out how the appointment went and find out the contact’s recommendations for the client or what next steps are needed. Getting to know specific professional contacts can help you with your client referrals, and you may also become a trusted resource to the other organization.

Takeaways and tips in the referral process

Tips for success for making good referrals for your clients:

• Research local organizations that are successful at helping clients with needs that generally match your clients’ needs, including cultural competence, language and physical accessibility, transportation, hours and days of operation, and the organization’s capacity to take on new clients.
• Make personal connections at organizations where you frequently want to send referrals.
• Get your client’s buy-in before you give them a referral. Give them encouragement and share your impression of the organization, and tell them what they can expect when they make contact there.
• Make a “warm handoff” by introducing your client to a contact at the receiving organization.
• Follow up with the client and the other organization after the scheduled first contact, to find out if the referral was successful and learn next steps for the client’s success.