1. Nickie Bazell & Jacob Smith Yang Capacity for Health Asian and Pacific Islander American Health Forum December 16, 2014

2. Organizational Development and Management Prevention with Positives HIV Policy & Planning Health Departments Organizational Development and Management Prevention with Positives HIV Testing Community Based Orgs Capacity for Health (C4H) provides free trainings and one-on-one technical assistance to community-based organizations and health departments

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4.  Describe the recent funding shifts, changes in HIV/AIDS prevention, and treatment advances  Discuss the current state of ASOs/CBOs in terms of fiscal health, medical capacity, leadership and governance  Recommend sustainability strategies

5. Chicken Licken

6. 1993 CDC Mandates CPGs 19812003 Advancing HIV Prevention Initiative 1995 Protease Inhibitors 1999 DEBIs

7. Quotes that resonate with you and your organization How does my organization reflect these profiles, challenges, and opportunities ? What are the lessons learned? What are the ways in which we might need to change How do I see myself in the future of HIV/AIDS?

8. “ Funding Cuts Force Group to End Free HIV/AIDS Testing” Union Leader (Manchester, NH), June 2012 “Boston Living Center Merges with Victory Programs” bostonlivingcenter.org, March 2012 “Colorado AIDS Groups Merge to Provide Clout” Denver Post, October 2011 “Local HIV/AIDS Agencies Fight for Life as State, Federal Aid Falls” Press Democrat (Santa Rosa), August 2012 “North Texas AIDS Agencies Face Funding Cuts ” CBS News, September 2011 “AIDS Groups in Ohio Merge ” The Chronicle of Philanthropy, May 2011 “We’re Going to Be in Trouble: AIDS Groups Plan for Funding Cuts ” The Atlantic, December 2011 “South Jersey AIDS Group to Close ” Cherry Hill Courier-Post, June, 2010 “Maine AIDS Alliance Closing its Doors” mpbn.net, March 2011 “AIDS Agencies Scramble for Funds ” Boston Globe, August 2011 “Silicon Valley AIDS Center to Close ” San Jose Mercury News, November 2010 “Memphis Gay and Lesbian Center’s HIV Testing Program Suspended After State Funding Cut ” Commercial Appeal, February 2012

9. Affordable Care Act Funding Environment Treatment as Prevention

10. 3 Domains 1.Fiscal Health 2.Medical Capacity, including HIV testing 3.Leadership and Governance Key Features Participant confidentiality Questions pre-tested Report reviewed by key provider Spanish language surveys and interviews

11. Media review : 174 print articles within a 5-month period Review of 154 IRS 990s: 45 organizations in 14 states 50-question survey: 48 organizational responses Key informant interviews: 36 people Participating ASOs/CBOs: 129Participating States: 37 plus Washington, D.C. Attention to diversity: size, geography, main audience, and other considerations

12.  Year-end operating deficits. In nearly half of reporting years, agencies reported a loss or minimal surplus.  Operating losses. 15% of agencies reported losses for three consecutive years.  Weak fund balances  considerable financial vulnerability.

13.  Deficits. 22.6% reported deficits in their last full fiscal year. The highest, proportionately, was a loss of $360K on a budget of $800,000  Almost deficits. Another 36.9%, reported performance that was essentially neutral  Low fund balance. 8.3% reported fund balances less than $100K  Cash on hand. 19% of the total reported having less than $100,000 in cash and marketable notes  Closures/Earnings. A handful on the brink of closure. On the other end, a handful of organizations had robust earnings/assets  Mergers. Nearly all (93%) agencies had at least considered merging with another agency. Nearly half (43%) reported considering the development of shared service partnerships with other agencies.

14. Strategies used in last 3 years to manage finances:  14%“Spent down reserves to cover operating expenses”  8%“Borrowed funds / line of credits to cover normal operating”  5.5%“Sought advances on grants or contacts to cover expenses”  5.5% “Delayed paying bills beyond a normal period”  5.5% “Initiated ‘emergency fundraising’ to cover expenses”  2.7% “Delayed/reduced payroll”

15.  “There’s so much federal uncertainty now, and it’s hard on us.”  “Funding changes have made us ask tough mission-related questions... like, ‘do clients truly have the same needs they did ten years ago?’”  “We’ve merged with multiple agencies in recent years.”  “The uncertainty of Ryan White funding is a constant worry.”  “I don’t think about the finances. I think about the quality of services.”  “We’ve greatly reduced our [cash] reserves.”  “Three years ago I wasn’t worried about our mortgage, but now I am.”  “Our biggest challenges is cash flow. And our biggest problem is local government. They’re just not paying their bills on time.”

16. The overwhelming majority of organizations reported some current delivery of health care services: 92%Rapid Testing 72%Medical Case Management 66%Mental Health 56%Adherence Counseling 56% Patient Navigator Services 48%STI and Other Health Screenings 35%Addiction Treatment 17%Pharmacy 14%Physician

17. Nearly all organizations (92%) reported the desire to initiate or expand some form of current medical services, either directly or through a partnership 4 Approaches 1.Creation of an FQHC or FQHC look-alike clinic 2.Partnering, with significant co-location of service delivery and access, with an existing clinic 3.Provision of a marketable “bundle” of support services to an existing clinic through a partnership agreement 4.Expansion and sustainability of current ancillary care models—essentially “staying the course”

18. 51% expressed significant interest in becoming or partnering with a clinic 2 Models For those planning FQHC or FQHC look-alike services or service expansions approaches focused on: 1.an infectious disease, such as HIV and hepatitis 2.a chronic disease, especially those linked to poverty, such as HIV or diabetes. Most common barrier: Lack of financial resources

19. 55%help developing financial estimates and fundraising plans 23%help assessing the local “market” and its specific needs 12%help defining an effective and sustainable service mix 37%“roadmaps” or “checklists” that will guide agency planning and action

20.  “We must add medical services to stay competitive!”  “We’re going to have to engage a consultant to walk us through the steps for establishing medical services.”  “We must add medical services to stay competitive.”  “We have been traditionally an HIV prevention agency. The changes in health care financing are new for us, and we’re in uncharted territory.”  “ We’d like to become a service support arm to another entity that can bill insurance, like our local community hospital.”  “We are experiencing significant barriers related to our work in ‘medical home’ models—feeling ‘shut out of’ health care reform processes.”  “We only want to provide medical services through co- location—our board has decided we don’t need the liability.”

21. Strategic plans seem to address shifting environment 81% of respondents reported that their agency had a current, active strategic plan Lower ratings for Board Knowledge: Board KnowledgeAverage Score Knowledgeable about HIV/AIDS care, services, and prevention 3.9 Knowledgeable about HIV/AIDS public policy and financing3.7 Knowledgeable about overall nonprofit management4.4 1 = “No Knowledge” 10 = “Completely Knowledgeable” Board Knowledge

22.  “It’s hard for me to stay current, much less do that for my board.”  “I find that we need to continually clarify the role of the board in terms of policy and fundraising.”  “When I first came here there were seven board members, no board giving, no board performance metrics. I’ve worked very hard to change that.”  “I’ve become convinced that board-building is critical. Our current chair is an HR professional, and we just re-wrote all our policies and procedures.”  “We’re growing rapidly but don’t have a strategic plan.”  “We do a training session at every monthly board meeting on fund-raising.”  “We’ve just been through a strategic planning process, but now we need an operational plan. We need to get staff focused on program achievement—nurture cross-silo conversation about outcomes.”

23. Many, but not all, organizations have struggled financially. While some report a relatively robust financial picture, a handful may be on the brink of closing. Many organizations in the middle are highly vulnerable to shifts in funding. “We’re holding our heads above water, but just barely sometimes.”

24. Nearly all organizations believed that community- based services should be better integrated with medical services. Many are taking steps in that direction, despite obstacles and confusion. “We need to provide medical services but don’t have the expertise, board buy-in, or resources. It’s a steep climb.”

25. Significant reports of frustration in engaging/informing high-functioning boards. Some also expressed need for senior staff leadership development. “Board recruitment— getting really good people and keeping them for the long haul— is a continuing challenge.”

26. #1: Provision of assistance to effectively define, implement, and finance the service model that will characterize the organization’s future.

27.  “We need help with public relations. AIDS is not over and we need to convince the public that that’s true.”  “ Leadership development for staff. We have to adapt to these changes, which will require different skill sets.”  “We need help constructing data models for evaluation, performance monitoring, and billing. It’s getting more and more complex all the time.”  “Some of our big fundraisers are vulnerable because they depend on so many variables. We need help figuring out how to wean ourselves...”  “We need help with planning —including operations planning.”  “We need help navigating the new terrain of EMRs [Electronic Medical Records]. Even the feds are confused.”  “Designing and implementing QI and QA.”  “We need help dealing with the legal issues of downsizing or expanding... the HR process. No one is talking about that.”

28. 1.CBOs /ASOs should consider the business model that is best for their organization and the communities it serves. For instance, should the CBO/ASO: A. Partner with existing clinics, B. Expand medical services without evolving into a full clinic, or C. Become an FQHC or FQHC look-alike clinic. 2.CBOs/ASOs should become familiar with discrete elements of service expansion, especially: A. Health care financing and accounting; B. Market analysis to understand needs and market gaps, and, C. Expansion capitalization to finance start-up services.

29. 3.CBOs/ASOs should have a working and current knowledge of the Affordable Care Act, Ryan White CARE Act, and other federal programs, and should be used to inform the agency’s strategic, business, and/or operational planning efforts. 4.Awareness of successes and challenges of peer organizations; Emerging organizations pairing with successful organizations 5.ASOs/CBOs consider new models for earning income 6.When closing or ending an HIV program or agency – build in ample time to plan at the beginning of the process for client’s welfare

30.  Case studies of promising practices of ASOs and CBOs surveyed – business models

31. Ed Tepporn of the Asian & Pacific Islander American Health Forum’s (APIAHF) and Earl Pike served as the lead staff for this report. Jenny Panzo, MPH (New York) and Mireille Sjoblom-Kious (Cleveland) provided invaluable assistance in collection and analysis, as well as translation services. The Community and CBO leaders who participated in the survey and key informant interview process. Graphic design and layout services were provided by AJ Titong. This report was supported by Cooperative Agreement Number 5U65PS001651-04 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

32. www.apiahf.org/programs/hiv/capacity-for- health www.library.capacity4health.org

33. Contact us with additional questions and support! Nickie Bazell Capacity Building Director nbazell@apiah.org (415)568-3307 Jacob Smith Yang Senior Capacity Building Director jyang@apiah.org (415)568-3307

34.  Webinars are available on our website for on-demand viewing.  You will find slides from today’s presentation posted to the front page of our website: www.nationalhivcenter.org.www.nationalhivcenter.org  You also can find these slides and other capacity building resources at the C4H online library: www.library.capacity4health.org www.library.capacity4health.org  Please complete the evaluation at the end of the webinar. Your feedback will inform our programming.  If you are interested in individualized technical assistance, please visit our website and complete a TA Request Form.  Join us for our town hall meeting! National Center for Innovation in HIV Care: Town Hall Meeting Wednesday, January 14 at 1:00 PM ET (Find a link to register at our website: www.nationalhivcenter.org )www.nationalhivcenter.org Conclusion Slide