Case Management

A Strengths based case management model is used by the HIV Outreach Team to assess and assist clients in developing their care plan. The model is underpinned with self- management principles assisting the client in learning the skills required to become good self-managers.

The HIV Outreach Team works with specialist health and social services to meet the needs of the client. This includes advocacy and referral to specialist services. We also assist clients with access to the NDIS.

Our model places the client at the centre of everything we do with them. The HIV Outreach Team promotes self-determination and empowerment. Each client has control over formulating strategies unique to their personal needs to achieve the best health outcomes. 

The HIV Outreach Team supports clients with a range of medication adherence strategies such as:

  • liaison with S100 prescribers around the managements of medications and scripts
  • organising blister packaging through community pharmacies
  • provide dosette boxes for clients to self-manage their medication
  • medication prompts/reminders for clients on a short term basis
  • daily observed therapy on a case by case basis ( Monday - Friday only)
  • using visual aids and diaries to help support clients with cognitive issues

We work with clients and specialist agencies to provide information about medications, support with identification and management of side effects from ARV therapy and can advocate for clients concerning their health and wellbeing. Specific ways we can assist clients include:

  • support around medication efficacy and self-management
  • information about medication and their side effects
  • attending medical appointments with clients
  • assisting clients who are physically unable to collect medications
  • organising referrals to the Bobby Goldsmith Foundation for financial support for medications
  • referral to dietitian to help with the processing of medications and help manage side effects
  • provide support around treatment options and adherence

Upon referral, the HIV Outreach Team has the capacity to assess and refer clients for mental health support.

People living with HIV have higher rates of depression in comparison to the general population (1). People living with a severe mental illness in Australia live significantly less than the rest of the Australian population (2).

The team does not provide acute mental health care or replicate formal mental health services, but works in partnership with agencies that provide specialised community mental health support.

The partnerships include community mental health providers/teams, General Practitioners, Inpatient Mental Health Units, HIV clinics and families/carers.

Mental health support provided includes:

  • formal and informal mental health assessment and specialised community mental health support in the context of HIV
  • psychosocial support
  • Advocacy to improve engagement and access to mental health care
  • Assisting in the prevention of mental health crisis and avoiding presentations to emergency departments and mental health crisis teams and hospital admissions.
  • supporting HIV and mental health services to provide comprehensive specialist health care for people living with a severe mental health condition
  • HIV/mental health consultation to government and non-government agencies

The mental health approach used by the HIV outreach team is holistic and involves integrating people’s physical health, mental health and psychosocial wellbeing. Care provision is on an individual basis and is client led.

1. NSW HIV Strategy 2012-2015 A New Era, NSW Health

2. A Contributing Life: the 2013 National Report Card on Mental Health and Suicide Prevention, National Mental Health Commission

The HIV Outreach Team has a Needle and Syringe Program (NSP) services for clients of its service. 

The NSP aims to reduce the transmission of blood borne viruses among people who inject drugs by minimising injecting related risk behaviours e.g. the sharing and/or reuse of injecting equipment. In addition to providing new injecting equipment, the NSP delivers education, health promotion and brief interventions, and is often viewed as a gateway to other health and welfare services.

As a secondary NSP, the HIV Outreach Team currently services a small number of clients who inject drugs on a regular basis. The service is only provided to clients who are seen as particularly vulnerable and do not consistently access established primary NSP providers and report ongoing sharing of injecting equipment with others.