Developing a Single Planning Approach to HIV Prevention, Care, and Treatment in Los Angeles County

1. LOS ANGELES COUNTY COMMISSION ON HIV HIV INTEGRATED PLANNING Developing a Single Planning Approach to HIV Prevention, Care and Treatment in Los Angeles County Unification of LA County’s Two HIV Planning Bodies November 21, 2013

2. Presentation OVerview I. Los Angeles County EMA II. Impetus for Integrated Planning III. Process for Integrated Planning IV. The New Configuration V. Lessons Learned

3. I. Los Angeles County EMAEMA Description LOS ANGELES COUNTY  Most populous county in US.  Greater population than 42 individual states.  88 incorporated cities and many unincorporated areas.  One of the most racially/ ethnically diverse areas in the US.  Urban, suburban and rural areas.  Divided by the San Gabriel and Santa Monica mountain ranges.

4. I. Los Angeles County EMA2013 Estimated Number of Persons Living with HIV and AIDS in LA County (1) Estimate that 18.1% of HIV+ in LA County are unaware of their infection; modified from CDC estimate. (2) Of 4,853 notifications pending investigation, estimate half of 2,400 who have detectable VL or confirmatory test to be unduplicated cases. (3) Of 4,200 notifications pending investigation, estimate about 2,000 who have detectable VL or confirmatory test to be unduplicated cases.

5. I. Los Angeles County EMADivision of HIV and STD Programs (DHSP) Integration Announced February 2011 Organizationally realigned the former HIV Epidemiology Program, Office of AIDS Programs and Policy and STD Prevention and Control Efficiency and evidence-based driven Largest fully integrated local health department Controls all HIV and STD health department programming

6. I. Los Angeles County EMADHSP Projects and Programs HIV and STD Prevention and Control HIV Testing Services Targeted, Routine, Social Network, Mobile Unit-Based STD Screening and Treatment Support Public Sector/Private Sector HIV Care and Treatment Services Integrated Behavioral Health in Primary Care Settings Navigation, Linkage, Retention Initiatives Geographic-specific STD Control Effort

7. I. Los Angeles County EMADHSP Projects and Programs (cont.) Syndemic Planning and Geospatial Analysis Use of Surveillance Data/Data Matching/Data Sharing Public Health Investigation and Use of Community Embedded Disease Intervention Specialists Biomedical Interventions (PEP) Integrated TLC+, PrEP and Social Network Testing Housing Services Coordination with HOPWA Medical Care Coordination Integrated Community Planning

8. I. Los Angeles County EMASharing Data to Improve Planning Evaluate HIV/STD surveillance, program, and other data to identify areas for programmatic focus, inform planning processes, and implementation strategies by: Matching HIV/STD surveillance and program data to evaluate testing, linkage, retention, and viral load suppression across the spectrum of engagement in care, Use of HIV/STD surveillance data to identify geographic areas and populations most impacted by HIV/STD syndemics, Improve accuracy and efficiency of data collection and facilitate useful reporting.

9. II. Impetus for Integrated PlanningChange is Hard Accepting that transformational change of any type is difficult—it creates anxiety and disquiet (even among those who support it), and will be full of unexpected events and turns—before you begin . . . is key to a process that, eventually, finds its way to the desired result. “It’s going to be messy. Whether you support it, or whether you oppose it . . . it’s going to be messy.” David Brooks, political pundit, on health care reform “It’s going to be messy. It’s going to be politically contentious. But it—in the end—it’s going to happen.” EJ Robinson, political pundit, in response to David Brooks

10. II. Impetus for Integrated PlanningExternal Factors Improved planning and coordination of services and resources— National HIV/AIDS Strategy (NHAS) Treatment Cascade (national “Continuum of Care”) Early Identification of Individuals with HIV/AIDS (EIIHA) Testing, Linkage to Care, Treatment Plus (TLC+) Enhanced Comprehensive/HIV Prevention Planning (ECHPP) Emergence of disparities/inequities/social deter-minants as a key Commission focus and priority

11. II. Impetus for Integrated PlanningInternal Factors Implementation of the Affordable Care Act (ACA): Need to improve service delivery efficiency and reduce duplication of effort Prospects of additional savings and resources Need to generate more enthusiasm/momentum for HIV prevention planning after CDC changes Consistent with the Commission’s strategic plan Possible reductions in federal and state Ryan White/federal appropriations and other resources

12. II. Impetus for Integrated PlanningNumerous Earlier Efforts to Integrate 1) Commission and PPC attempted merger in 2002: Commission approved it; PPC opposed it—unanimously PPC was concerned that care/treatment focus would shift attention away from prevention, Commission’s relationship with DHSP concerned PPC, The planning body votes created hard feelings/ resentments for a decade. 2) Quarterly joint Co-Chair meetings not successful. 3) Joint Public Policy (JPP) Committee formed, 2008: Three separate attempts to integrate policy work, Both bodies’ single policy unit for five years.

13. III. PROCESS for Integrated PlanningMilestones on the Path to Unification 2013 2011 2009 2012 2010

14. III. PROCESS for Integrated PlanningChange Leaders In 2009, Commission and PPC formed a joint “Integration Task Force” to improve collaboration and exchange between the two planning bodies— The first year was spent educating members about the full range of LA County’s HIV services and activities—and defining terminology acceptable to both groups; Began integrating care/prevention services/interventions into a TLC+ framework; ECHPP eventually became the predominant strategic prevention approach.  Task Force recommended, and Commission/PPC agreed —to develop an integrated Comprehensive HIV Plan.

15. III. PROCESS for Integrated PlanningCatalysts for Change Transformation depends on “change leaders” capable of ascertaining when timing and momentum are right for change (“catalysts for change”): Following International AIDS Conference (IAC), where “treatment as prevention” was predominant; Improved relations between two planning bodies due to joint development of Comprehensive HIV Plan; Diminished enthusiasm for HIV prevention planning due to limited role in CDC’s new HIV Planning Guidance; In preparation for ACA roll-out, HIV service delivery will be re-organized/re-structured on a broader scale.

16. III. PROCESS for Integrated PlanningComprehensive HIV Planning (CHP) Task Force Integration Task Force becomes Comprehensive HIV Plan (CHP) Task Force, to oversee Plan development. Final Los Angeles County Comprehensive HIV Plan 2013 – 2017 submitted to HRSA and CDC, 3/2013: Links HIV prevention, care and treatment services to NHAS goals, treatment cascade, and ACA; Local continuum of care consistent with local/national priorities; addresses disparities/health inequities; Goals/objectives to be monitored/updated annually.

17. III. PROCESS for Integrated PlanningFramework and Parameters FRAMEWORK: The term “unification” was selected carefully—to represent a union of interests, rather than one interest consuming or absorbing the other. TIMELINE: Commission and PPC agreed to complete the process in six months—by July 2013—because: procrastination weakens stakeholder resolve/enthusiasm; the HIV planning body could not devote more time to unification with ACA implementation advancing so rapidly; unification needed a sense of urgency to generate a timely County response (from other, necessary departments).

18. III. PROCESS for Integrated PlanningBuilding Community Consensus Following successful development of the CHP, the Commission agreed (unanimous) to “merge” in Spring 2012; PPC agrees (unanimous) in September 2012: Two (2) co-chairs from the Commission/and 2 from the PPC; Merger is formally renamed a “unification”; and CHP Task Force agrees to an expedited timeline.

19. III. PROCESS for Integrated PlanningAnticipated Challenges CHP Task Force anticipated the following challenges: Generating/maintaining stakeholder support/enthusiasm; A continuing, relevant role for HIV community health planning after implementation of the ACA; Integrating HIV care and prevention perspectives into a single, jurisdictional HIV response; Presenting HIV care and prevention in a balanced manner that gives both perspectives sufficient consideration; Synchronizing planning, priorities, allocations and standards of HIV care and prevention; Effectively blending two distinct organizational cultures.

20. III. PROCESSfor Integrated PlanningChanging Organizational Culture Los Angeles County Prevention Planning Commission on HIV Committee (PPC) Planning Body Cultural Characteristic Planning Body Cultural Characteristic Meeting Type County Role Membership Meeting Purpose Work Origins Ave. #/Members Reports To Community Interest • Outcome • Authority • Consumer • Decision/Action • Committee-driven • 35-45 members • Reports to BOS • > Audience • Process • Advisory • Planner • Inform/Dialogue • Hybrid • 15-25 members • Reported to DHSP • < Audience

21. III. PROCESS for Integrated PlanningStrategies for Effective Forward Progress

22. III. PROCESS for Integrated PlanningStakeholders: Administrative Mechanism Organization LA County Board of Supervisors [Chief Elected Official (CEO), per Ryan White (RW)] LA County Chief Executive Officer (CEO) Executive Office of BOS Department of Public Health (RW Grantee) Commission on HIV (RW Planning Council and HIV Planning Group) Division of HIV/STD Programs (RW Administrative Agency) Providers Other Stakeholders Consumers

23. III. PROCESS for Integrated PlanningCounty Code 3.29 (Ordinance)

24. III. PROCESS for Integrated PlanningTechnical Assistance (TA) Consultant

25. III. PROCESS for Integrated PlanningUnification Timeline Timeline: • CHP Task Force and TA revise Commission Ordinance/By-Laws February 2013 • Revised By-Laws submitted to Commission/project officers March 2013 • Commission/PPC approve plan for transitional Open Nomi- March 2013 nations process to recruit/select new members • Membership application, evaluation/scoring materials revised April 2013 • Membership applications due April 2013 • Membership interviews May 2013 • Commission/PPC nominates members to BOS May 2013 • Commission/PPC approve revised By-Laws May 2013 • BOS appoints new members at two separate meetings June 2013 • New membership seated at new Commission’s inaugural meeting/July 2013 10. Ordinance approved by BOS June 2013 11. Ordinance authorizing new Commission enacted/membership July 2013

26. III. PROCESS for Integrated PlanningFundamental Membership Decisions MEMBERSHIP: The formation of a unified planning body requires a new membership, and is enacted when the new members are installed: a limited number of membership seats would be added (Board of Supervisors concern); equal attention to RWPA and CDC guidance—even though RWPA “requires” and CDC only “recommends” specifics; anyone wishing to serve on the new planning body must (re-)apply—regardless of a candidate’s current planning body member status or participation on the Task Force.

27. III. PROCESS for Integrated PlanningTransitional Open Nominations Process

28. III. PROCESS for Integrated PlanningMembership Results Transitional Open Nominations Process Results: 46 membersand 15 alternatesappointed by the BOS—leaving only five (5) seats vacant. • Complies with “reflectiveness”/ “representation” requirements from RWPA, and CDC’s Parity, Inclusion and Representation (PIR) recommendations; • Three types of members on the new Commission: returning Commission members, returning PPC members, and new members —representing educational/ orientation challenges. Membership: 79 applications submitted by first deadline. Interest in joining the new Commission far exceeded the projected response, in part due to (as expressed by applicants): • Unification generated community enthusiasm; • HIV stakeholders got involved due to changes; • Applicants felt it was a new organization; • It was an opportunity to bring new issues; • Applicants excited about the new direction. Still Unresolved: defining “HIV prevention” consumer organizationally.

29. IV. New ConfigurationTiming of Decisions/Actions It was necessary to make decisions concerning organization, structure and authority prior to unification--all other decisions were left for the Commission to make after unification.

30. IV. New ConfigurationCommittee/Organization Structure Committee/caucus structure remained mostlyunchanged. Functional organi- zation around the type of work, rather Consumer Caucus Latino Caucus Transgender Caucus Community Engagement Task Force than topic or content. Each commit-tee deals with care and prevention issues equally, not in “service siloes.” • Legislation • Budgets/Funding • RegulatoryAffairs • Benefits • Intergovernmental Affairs/Interaction • Membership • Assess. Admin. Mech. • Policies/Procedures • Public Awareness • Comprehensive Training Program • Comp. HIV Plan • Priorities/Allocations • Needs Assessment • Expenditure Review • Directives,Program Models, Services • HIV Continuum • Standards of Care • Best Practices • Key Populations • Determinants, Barriers, Access

31. IV. New ConfigurationImmediate Post-Unification Work Integrating two HIV planning groups...only the first step! POLICIES/ PROCEDURES What policies/procedures are important now, need to be revised, and how? MEETINGS How does organizational culture get addressed through public meetings? and, . . .some work goes on— indifferent to the time-consuming nature of integration! Still much work left to do before Commission can claim full HIV planning integration . . .

32. V. LESSONS LEARNEDEnacting the New Commission Much of the work occurs afterwards Stakeholder investment/buy-in Support of the grantee/CEO Right/opportune timing “Consumer” definitions Jurisdictional similarities Aggressive timeline Creating enthusiasm and momentum

33. V. LESSONS LEARNEDFive Things Wish We Had Known Entering the Process Issue #1: How do we define “HIV-negative or prevention consumer” [vs. “unaffiliated (HIV-positive) consumer” from HRSA]? Issue #2:How do we integrate very different “cultures” of the former Commission and former PPC? Issue #3:What is the meaning of “integration” in an organizational setting (vs. used as a programmatic reference)? For example, what are the indicators that an organization has successfully integrated, vs. successfully collaborated or partnered? Issue #4:How do we allocate funds for prevention activities that have already been determined? Issue #5:What are the decisions that must be made before two planning groups can integrate (vs. what decisions can be left to the planning body to make after it has integrated)?

34. V. LESSONS LEARNEDLeading Change: Why Transformation Efforts Fail by John K. Potter

35. CONTACTSfor Further Information Los Angeles County EMA Grantee/Administrative AgencyPlanning Council Michael Green, PhD Craig Vincent-Jones, MHA Chief of Planning Executive Director Division of HIV/STD Programs Los Angeles County Commission on HIV 600 Commonwealth, 10th Floor 3530 Wilshire Blvd., Ste. 1140 Los Angeles, CA 90005 Los Angeles, CA 90010 213.351.8002 213.738.2816 mgreen@dph.lacounty.gov cvincent-jones@lachiv.org