FFOOCCUUSSWhile emotional support and risk

reduction counseling may form thecore of the relationship between HIVantibody test counselors and theirclients, test counselors also serve acritical role in helping clients gainaccess to other services. These ser-vices—including food, shelter, trans-portation, medical care, and financialassistance—are important not only tothe general welfare of clients but alsoin terms of their susceptibility toengage in HIV-related behaviors andtheir abilities to take care of them-selves if they are infected.

Without help accessing these ser-vices, however, clients may becomeconfused about or overwhelmed bythe options available to them. As aresult, they may fail to seek servicesor they may use inappropriate ser-vices. This is exacerbated by fundingshortages: in response to the scarcityof services, clients may attempt toaccess services from programs notdesigned to serve them, and this maytax existing resources.

Help may take several forms:assessment of services needed, educa-tion about the range of services, andsupport in accessing and coordinatingservices. Help may be providedthrough a variety of service deliverymechanisms ranging from informa-tion and referral-giving, throughclient outreach and advocacy, to casemanagement. It is important forcounselors to understand these mech-anisms for service delivery in order tohelp clients understand which ofthese services they may need andwhat their options are after test coun-seling. This article describes themechanisms for service delivery andexplores the test counselor’s role inassessing client service needs andfacilitating access to services.

Service DeliveryInformation and referral-giving,

client advocacy, and case manage-ment represent a continuum of ser-vice delivery methods. Informationand referral-giving is the process bywhich clients obtain basic informationabout services that are available andreferrals to service providers.

Advocacy involves either assistingclients in building the skills they needto seek services on their own oractively advocating on their behalf.Case management is the most com-prehensive form of service delivery. Itincludes components of information-and referral-giving and client advoca-cy, and can extend beyond these to ahighly structured relationship thatinvolves hands-on management of aperson’s daily activities and serviceneeds.

Information and Referral. Of theseservices, test counselors most oftenfill the role of information and refer-ral providers. In addition, informationand referral services are perhaps themost frequently provided form ofsupport from HIV-related serviceorganizations. This method mayinclude providing a client withresource materials, informationalhand-outs and brochures, telephonelists of resources, or names of contactpeople for specific services. In makingreferrals, test counselors shouldexplain the nature and extent ofservices available and any require-ments for accessing services, such aspresenting a letter of diagnosis ofAIDS or symptomatic HIV infection,proof of income, or proof that clientshave exhausted other options.

In some cases, clients may obtaininformation and referral services onlyafter a provider has completed anintake interview, an assessment, and atreatment plan for the client. This isgenerally part of the client registrationprocess. In others, information andreferral is more casual and may beprovided anonymously over the tele-phone. Information and referral recom-mendations are usually not tracked andcan be provided by a range of staff,including receptionists, volunteers, hotline staff, and computer- or telephone-based information operators.

Client Advocacy. Client advocacygoes beyond information and referralby actually facilitating initial contactbetween a client and other serviceproviders. Typically, client advocatesrespond only to problems that can beresolved without lengthy intervention.Advocates can assist with housing

needs, finances, medical care, andtreatment for mental health or sub-stance abuse issues. Advocacy isespecially helpful for clients who areable to refer themselves or for clientswho may require temporary assis-tance in adequately utilizing services.In this context, antibody test coun-selors may work with clients to pre-pare them to advocate for themselves.

Unlike information and referral,however, advocacy is usually provid-ed by professionals or volunteers whoare trained to understand access andservice utilization issues. Clientadvocacy can be especially beneficialfor clients who are seeking HIV-relat-ed early intervention or pre-disabilityplanning services.

Case Management. Case manage-ment, the most formal and tightlymanaged of the client-centered sup-port services, includes advocacy;supervision and oversight of theclient’s plans, goals, and needs; sup-port; information and referral; andlinkage, that is, providing specificssuch as contact names and agencyhours. Case management might be themost appropriate service in light of thenumber or severity of issues facing aclient. It may also be most appropriatefor clients who cannot complete sim-ple tasks because of illness or cogni-tive impairment. Clients who havebeen diagnosed with two or moredisorders such as substance abuse anddepression, are especially good candi-dates for case management.

The objective of case managementis twofold: first, to make life moremanageable for clients; and second, tomake the system work better by help-ing disorganized or crisis-riddenclients sort out the multitude of needsand approaches for facing them. Thestrength of case management is itsconsistency of interaction, helpingclients to more easily respond to theirown changing needs and for providersto have the luxury of planning servicesin an organized way. The case managerbecomes a pivotal contact between theclient and other service providers andis sometimes responsible for helpingthe client manage and coordinatevarious aspects of his or her care.

Case management may be a valu-able short-term measure to assist aclient in responding to a particularlydifficult course of events or dealing

Volume 10 Number 7 June 1995Supplement to FOCUS: A Guide to AIDS Research and Counseling On HIV Antibody Test Counseling

Understanding Service DeliveryMichael Lee, LCSW

with specific but complicated needs such asreceiving medical insurance, applying forbenefits, enrolling in HIV-related drug treat-ment trials, and navigating governmentbureaucracy. For some of these reasons, acounselor, social worker, or client advocatemay organize a meeting that includes all theservice providers who are involved with aclient. Such a meeting may focus on when orwhy case management is indicated, what mightbe accomplished by encouraging the client toparticipate in this process, and how providerscan identify and work together toward specificgoals.

Clients may obtain support services frommore than one person and simultaneously ateach point along the service delivery continu-um. Interactions may involve one-time tele-phone contact with providers not necessarilyknown to the client; occasional contact with anoutreach worker or counselor; or oversight andsupervision of a client’s daily affairs by a socialworker. Case management relationships—whena provider acts as a broker or coordinator ofservices—often involve the most interaction.However, even in these relationships, clientsmay not have ongoing contact until or unlesschanges in the client’s situation make it neces-sary. Case management may be time- or task-limited. Time-limited services may, forinstance, extend for a period of three to sixmonths from the date case management ser-vices begin. Task-limited services are centeredaround the number of needs identified; casemanagement ceases when tasks have been met.

When Are Services Needed?Clients require support services when they

or their service providers identify or anticipate“unmet” needs. This can occur when clients areunable to access services or follow through tothe point of resolving their needs. A client’sneed for services is influenced by the exis-tence of other support in his or her life. Arelatively high-functioning client with a part-ner or supportive family members may needoutside direction infrequently. People withoutintact support systems may rely more heavilyon an agency’s support services, especially asconcerns become more significant, complex,and urgent. This may be especially true for aclient who has multiple challenges, forinstance a substance user who is also home-less and without health care and is receivingservices from several agencies.

In general, service needs for seronegativeclients are different from those for seroposi-tive clients. People who are not infected mayrequire support in preventing infection andhelp in dealing with the emotional stress ofliving in the epidemic, specifically in terms ofmatters such as multiple loss and feelings ofguilt at being free of HIV infection whilefriends or others are infected. This supportfocuses primarily on referral and follow-upservices in order to enable clients to makeinformed decisions concerning risk reduction,substance use, and other choices in their lives.

Seropositive people also benefit simply fromeasy access to information about treatment andsupport services, including details about when

these services can be accessed, the extent ofservices, and criteria for receiving them. Amongthese services are early intervention programsand intake and assessment services. After deter-mining which problems to focus on, counselorsshould clarify clients’ past attempts to resolvethese issues and then make recommendations—based on the severity or complexity of theissues—about where along the continuum ofservice delivery the client might access services.

Assessment and ReferralThe coordination of a client’s services with

the help of an outside provider can begin in therisk assessment session of test counseling.When clients relate significant issues—such assubstance abuse, homelessness, or lack ofhealth care—that may contribute to possible HIVinfection, counselors should acknowledge theseriousness of these concerns and briefly assessclients’ prior or current efforts to respond.Counselors might then present referrals, detailthe process of seeking services, for instancethrough self-referral or through more formalchannels, and further explore clients’ intentionsor abilities to pursue assistance. Throughout theprocess, it is important for counselors to recog-nize that clients may be influenced by what hasworked or not worked for their friends and forcounselors to respect these experiences.

Encourage clients to learn about supportservices before they actually need them. Forpeople receiving positive test results, presentthe option, when available, of a group orienta-tion meeting in which they can receive a broadamount of information, ask further questions,meet others with HIV infection, and perhapsmake initial appointments for services.

In addition to assessing the seriousness ofclients’ concerns, counselors might assessclients’ abilities to seek help on their own, andthen provide them with a framework ofoptions. Counselors can ask clients if they arewilling to speak to an intake worker or socialworker about the prospect of receiving casemanagement until their more serious issueshave been addressed or resolved. Counselorsmight also suggest that clients may simplyneed a consistent source of information.

In making referrals, counselors should pro-vide direction and guidance as to how and whenclients might access services. This is especiallytrue when counselors are addressing longstand-ing issues such as mental health, chronic healthconcerns, substance abuse, homelessness, andfinancial instability. Near the end of the testcounseling session, it is important that coun-selors provide a final opportunity for clients toask for help and for counselors to clarify theinformation they have presented.

ConclusionBecause their focus is often on providing

emotional support and helping clients developrisk reduction strategies, test counselors arelimited in the range of services they are able toprovide clients. By having a clear idea of themechanisms for service delivery and the rangeof support that clients can receive, counselorscan be better prepared to help clients movebeyond the session.

Michael Lee, LCSW is atrainer at the UCSF AIDSHealth Project and amedical social workerfor Kaiser Permanente.Among those whoprovided input to thisarticle were ChristopherSchmidt and JD Benson,MFCC.

2 FOCUS June 1995

Executive Editor; Director,AIDS Health ProjectJames W. Dilley, MD

EditorRobert Marks

Staff WriterJohn Tighe

Founding Editor; AdvisorMichael Helquist

Medical AdvisorStephen Follansbee, MD

MarketingMichal Longfelder

DesignSaul Rosenfield

ProductionJennifer CohenStephan PeuraKelly Van Noord

CirculationSandra Kriletich

InternsShirley Gibson

FOCUS On HIV AntibodyTest Counseling is a quar-terly supplement toFOCUS: A Guide to AIDSResearch and Counseling,both published by theAIDS Health Project,which is affiliated with theUniversity of CaliforniaSan Francisco.

The Supplement is pub-lished under a grant fromthe California Departmentof Health Services, Officeof AIDS, and is distributedto HIV antibody test sites.Permission to reprint anypart of the Supplement isgranted, provided acknow-ledgement of FOCUS andthe California Departmentof Health Services isincluded. FOCUS itself iscopyrighted by the UCRegents, which reserves allrights.Address correspondenceto: FOCUS, UCSF AIDSHealth Project, Box 0884,San Francisco, CA 94143-0884; (415) 476-6430.

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