Indianapolis TGA Planning Council Orientation

1. Indianapolis TGA Planning Council Orientation October 4, 2012 Ryan White/HIV Services Staff Planning Council Co-Chairs

2. The Planning Council • Purpose: • The planning council will serve as an advisory body to the Marion County Health Department to assist in preparing the grant application for continued funding. • Duties include assisting in setting priorities and allocation of funds for services on the basis of the size and demographics of the HIV population and the needs of the population. • Oversight of the needs assessment is the responsibility of MCHD Staff or their consultants. • Special attention is given to those who know their HIV status but are not in care.

3. Advocate versus Planner • Advocate • Calls attention to the needs of specific groups with HIV disease • Supports targeting of services to these groups • During needs assessment, ensures that the needs of his/her community are studied and documented • During comprehensive planning • Questions assumptions • Helps ensure that important factors are considered • Supports services appropriate for his/her community or population • During evaluation, provide the client perspective

4. Advocate versus Planner • Planner • In needs assessment and comprehensive planning, ensures that the needs of communities other than his/her own are studied and documented • In Decision making • Considers the needs of all communities and PLWH population groups in the service area • Prioritizes needs and allocates resources to services based on sound needs assessment data and objective criteria • Helps prevent and manage conflict of interest – including his/her own and that of other members • Takes responsibility for helping to ensure an equitable and methodologically sound-

5. Legislative Context: Facts and Factors Important to Planning Councils • Ryan White program uses a medical model • Increased focus on getting people into primary medical care and keeping them in care • Limits on non-service costs • Focus on ensuring all funds are used -- “use or lose” Part A funding

6. 1. Medical Model • Major focus on core medical services (medical model) • 75% of service funds must be spent on core medical services, newly defined (waiver available) – similar requirement in pre-reauthorization Title I program guidances • Up to 25% of service funds may be spent on support services that contribute to positive clinical outcomes

7. Core Medical Services 1. Outpatient and ambulatory health services 2-3. Medications: AIDS Drug Assistance Program (ADAP) and Pharmaceutical assistance 4. Oral health care 5.Early intervention services (EIS) 6. Substance abuse services – outpatient 7. Mental health services • Medical case management including treatment adherence • Health insurance premium & cost sharing assistance • Home health care • Home & community-based health services • Medical nutrition therapy • Hospice services

8. Support Services • Case management (non-medical) • Child care services • Emergency financial assistance • Food bank/home-delivered meals • Health education/risk reduction • Housing services • Legal services • Linguistics services (interpretation and

9. Supportive Services • Medical transportation services • Outreach services • Psychosocial support services • Referral for health care/supportive services • Rehabilitation services • Respite care • Substance abuse services – residential • Treatment adherence counseling

10. Support Services • Must be: • ≤25% of total service expenditures • Approved by the Secretary of HHS • Needed to achieve medical outcomes • Medical outcomes = outcomes affecting the HIV-related clinical status of an individual with HIV/AIDS • Planning Councils need to know allowable service categories and service definitions • Grantee and Planning Council need to be able to link funded support services to positive medical outcomes

11. Focus on Getting People into Care • Unmet need = need for primary health care among PLWH/A who know they are HIV+ & are not receiving HIV-related primary care • Major legislative emphasis on reducing unmet need • Improved testing means more people will be needing primary care • Challenge: number served vs. comprehensiveness of services • Important changes for long-time consumers

12. Indianapolis Unmet Need

13. 3. Limits on Non-Service Funding • Focus: maximize funding for direct services • 2006 legislation has a 10% administrative cap for grantee and Planning Council together • Another 5% for Clinical Quality Management – assess quality of care and clinical outcomes • Planning Council has no say in the amount or use of administrative or QM funds except for its own budget

14. Use or Lose” Part A Funding • Planning Council responsible for allocations and reallocations • Penalty for unobligated funds • If more than 5% of formula funds are unspent at the end of the year, EMA or TGA loses future funding

15. Key Facts about Ryan White Part A • Ryan White services are not an entitlement • Ryan White is the payer of last resort • Intent is to provide a continuum of care with equitable access throughout the service area • Key role for consumers of Part A services – through Planning Council and other types of involvement

16. Grantee and Planning Council Roles and Responsibilities • Grantee and Planning Council = two independent entities, both with legislative authority and roles • Some roles belong to one entity and some are shared • HRSA/HAB recommends separation of duties to avoid confusion of roles • Effectiveness requires communications, information sharing, and collaboration between the grantee, Planning Council, and Planning Council support staff – and ongoing consumer and community involvement

17. Grantee and Planning Council Roles and Responsibilities

18. Planning Council Functions

19. FunctionsNeeds Assessment

20. Functions Comprehensive Planning

21. FunctionsPriority Setting

22. FunctionsResource Allocation

23. FunctionsCoordination of Services

24. Roles and Responsibilities Other

25. Planning Council Formation and Membership • Council established by Chief Elected Official (CEO) -- Mayor appoints all members • Membership must meet legislative requirements: • Representation (17 required categories) • 33% unaffiliated consumers of Part A services • Reflectiveness (of the epidemic in the TGA) • Council must use an open nominations process • Bylaws may call for a grantee representative on the Council • The Planning Council may not be chaired solely by an employee of the grantee

26. Composition • Representation on the Council • Health Care Providers, including federally qualified heath centers; community-based organizations serving affected populations and AIDS service providers • Social service providers, including providers of housing and homeless services • Mental health providers • Substance abuse providers • Local public health agencies • Hospital planning agencies or health care planning agencies • Affected communities, including people with HIV disease and historically underserved populations • Non-elected community leader

27. Composition • Medicaid • Part B grantee • Part C grantees • Representative of organizations with a history of serving children, youth, women, and families living with HIV and operating in the area • Grantees of other Federal HIV programs, including but not limited to HIV prevention services • Representatives of individuals who formerly were Federal, State, or local prisoners, were released from the custody of the penal system during the preceding 3 years,and had HIV disease as of the date on which the individuals were so released.

28. Comprehensive Planning • Shared task, with Planning Council as lead • Roadmap or vision for HIV service delivery system in the EMA or TGA, usually for three years • Key focus: strengthening the continuum of care to address disparities and bring people into care • Must be consistent with Statewide Coordinated Statement of Need (SCSN) • Council develops planning process, plays primary role in consultant selection as needed, oversees process through a committee • Grantee participates actively, provides data support • Both suggest goals in their areas of responsibility • Council monitors progress; grantee provides data to monitor progress

29. Needs Assessment • Planning Council has primary responsibility and “ownership” – design, direct work or oversight of consultants or volunteers • Grantee provides support – data, procurement if a consultant is needed, staff assistance • Need active community involvement – especially consumers and providers • Need multi-year plan for assessing needs of PLWH in and out of care • Findings go in user-friendly formats as input to decision making, especially priority setting and resource allocation

30. HRSA/HAB Needs Assessment Components • Epidemiologic Profile • Assessment of Service Needs • Resource Inventory • Profiles of Provider Capacity and Capability • Estimation and Assessment of Unmet Need

31. In addition to Needs Assessment Data… Planning Council also uses: • Cost and utilization data by service category • Demographics of Part A clients • Quality Management findings by service category • Information on other funding streams

32. Interpreting the Needs Assessment: Putting the Pieces Together

33. Three Components of Priorities and Allocations • Priority setting: deciding what services and program support categories are most important for PLWH in the EMA or TGA • Resource allocations: deciding how much Part A funding to provide for each service priority (percent or dollars) • Directives to the grantee on how best to meet these priorities – e.g., what services for what populations in what geographic areas • Reallocation of funds during the program year

34. Priority Setting • Planning Council responsibility • Means determining what service categories are most important for PLWH in the TGA – unrelated to who provides the funding for these services • Grantee provides information – especially service utilization data – and advice, but has no decision-making role • Council must establish a sound, fair process for priority setting and ensure that decisions are data based

35. Directives • Planning Council responsibility • Providing guidance to grantee on how best to meet the priorities and other factors to consider in procurement • Often specify use of a particular service model, or address geographic access to services, language issues, or specific target populations • Must not limit open procurement by making only 1-2 providers eligible • Council needs to be aware of cost implications • Grantee must follow Council directives in procurement and contracting (but cannot always guarantee full success)

36. Examples of Directives • Funded primary care services must be available in each of the major jurisdictions • Providers must have bilingual staff in positions with direct client contact, including clinical staff • At least one substance abuse treatment provider must offer services appropriate for women with young children and pregnant women

37. Resource Allocation • Planning Council responsibility • Process of deciding how much funding to allocate to each priority service category • Must meet 75/25% requirement • Grantee provides data and advice, but has no decision-making role • Need a fair, data-based process that controls conflict of interest • Consider other funding streams, cost per client, plans for bringing people into care – so some highly ranked service categories may receive little funding • Usually use three funding scenarios – flat, increase, decrease

38. Reallocation • Planning Council role: must approve any reallocation of funds among service categories • Reallocation usually means moving funds: • From underspent providers to those in the same service category spending at a higher level, or • From underspent service categories to those spending at a higher level or with additional need • Grantee provides expenditure data by service category throughout the year and requests permission for reallocations as needed • Some grantees do regular “sweeps” or request reallocation permission at set times each year – rapid reallocations process very important to avoid unobligated funds

39. Coordination of Services • Shared responsibility of grantee and Planning Council • Focus on ensuring that Part A funds fill gaps, do not duplicate other services, and make Ryan White the payer of last resort • Involves coordination in planning, funding, and service delivery • Council reviews other funding streams as input to resource allocation • Grantee ensures that providers have linkage agreements and use other funding where possible – for example, help clients apply for entitlements like Medicaid

40. Procurement • Grantee role • No Planning Council involvement • Involves: • Publicizing the availability of funds • Writing Requests for Proposals (RFPs) • Using a fair and impartial review process to choose providers • Contracting with providers – and requiring that they follow standards of care (SOC) and meet reporting and quality management (QM) requirements • Contract amounts by service category or sub-category must be consistent with Planning Council allocations and directives

41. Contract Monitoring • Grantee role • No Planning Council involvement, except that it develops the standards of care that are included in contracts and used as a basis for monitoring • Involves site visits and document review for monitoring of • Program quality and quantity of services • Finances, including expenditure patterns and adherence to HRSA/HAB and municipal regulations in use of funds • Aggregate findings (by service category or across categories) should be shared with the Planning Council as input to decision making

42. Clinical Quality Management • Grantee plays primary role • Involves ensuring that: • Services meet Public Health Service and clinical guidelines and local standards of care • Supportive services are linked to positive medical outcomes • Demographic, clinical, and utilization data are used to understand and address the local epidemic • Grantee requires providers to develop QM plans, monitors based on quality standards, and recommends improvements • Council establishes standards of care for use in QM • Grantee reports to Council on QM findings by service category or across categories

43. Cost-Effectiveness and Outcomes Evaluation • Planning Council has the option of assessing the effectiveness of services offered – usually best done in coordination with QM • Grantee monitors cost effectiveness of services as part of QM • Grantees also measure clinical outcomes • Findings used by grantee in selecting and monitoring providers • Findings used by Planning Council in priority setting, resource allocation, and development of directives on service models

44. Assessment of the Administrative Mechanism • Planning Council responsibility • Should be done annually – directly or through a consultant • Involves assessing how efficiently the grantee does procurement, disburses funds, monitors contracts, supports the Council’s planning process, and adheres to Council priorities and allocations • Written report goes to grantee, which indicates what action it will take to address any identified problem areas

45. Planning Council Operations • Must develop bylaws, policies and procedures to ensure fair, efficient operations • Must have grievance procedures • Must manage conflict of interest (COI) • Major attention to new member recruitment, orientation and training • Much of work done by committees • Assisted by Planning Council support staff

46. Managing Conflict of Interest • Planning Council must have and enforce conflict of interest policies including disclosure • Conflict of interest occurs when a Planning Council member has a monetary, personal, or professional interest in a decision or vote • Being a consumer of a specific provider is not considered a conflict of interest • Planning Council should not discuss particular providers and members should not advocate for providers

47. How Planning Councils Manage Conflict of Interest Each member must: • Sign a Disclosure Form every year • Update the form if affiliations change • Declare any COI before discussion begins • In decision making about priorities and allocations: answer questions but not initiate discussion about their service categories • Not vote on priorities or allocations for categories where there is a real or perceived conflict of interest • Not vote on other matters where there is a conflict (e.g., hiring of consultants)

48. Grievances • Both Planning Council and grantee must have HRSA/HAB-approved grievance procedures • Council must have procedures to handle grievances related to deviations from its priority- setting and resource-allocation procedures – usually also covers other policies and processes • Grantee must have procedures to handle grievances related to: • The procurement and contract award process • Deviations from Planning Council priorities and allocations in contracts and awards or changes in them

49. Role of Planning Council Support Staff • Assist the Planning Council to carry out its legislative responsibilities • Staff committees and Planning Council meetings • Provide expert advice on Ryan White legislative requirements and HRSA/HAB regulations and expectations • Oversee a training program for members • Encourage member involvement and retention, with special focus on consumers • Serve as liaison with the grantee

50. Grantee Staff Roles with Planning Council • Attend and make a grantee report at Planning Council meetings • Regularly provide agreed-upon reports (e.g., costs and service utilization) • Provide advice on areas of expertise without unduly influencing discussions or decisions • Assign staff to attend most committees • Collaborate on shared roles • Carry out joint efforts such as task forces and special analyses consistent with roles and resources