You will collaborate with providers to mutually develop and establish an action or individual service plan with each client that identifies patient needs, goals, and planned courses of action to promote readiness for and adherence to complete HIV/AIDS treatments (i.e., counseling, special programs), and meets identified needs; monitors and documents the changing needs of the client through personal contact and by reviewing the care plan at least every six months. For EHE contracts that combine psychosocial needs within EHE Medical Care Management, you will understand mental health needs and basic needs such as housing, food, and clothing, and develop relationships with programs and agencies serving those needs and facilitate referrals, support, and assistance for your patients who lack those services.