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

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. The Planning Council

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 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- Advocate versus Planner

Legislative Context: Facts and Factors Important to Planning Councils 1.Ryan White program uses a medical model 2.Increased focus on getting people into primary medical care and keeping them in care 3.Limits on non-service costs 4.Focus on ensuring all funds are used -- “use or lose” Part A funding

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 1. Medical Model

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 8.Medical case management including treatment adherence 9.Health insurance premium & cost sharing assistance 10.Home health care 11.Home & community-based health services 12.Medical nutrition therapy 13.Hospice services Core Medical Services

1.Case management (non-medical) 2.Child care services 3.Emergency financial assistance 4.Food bank/home-delivered meals 5.Health education/risk reduction 6.Housing services 7.Legal services 8.Linguistics services (interpretation and Support Services

Supportive Services 9.Medical transportation services 10.Outreach services 11.Psychosocial support services 12.Referral for health care/supportive services 13.Rehabilitation services 14.Respite care 15.Substance abuse services – residential 16.Treatment adherence counseling

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 Support Services

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

Indianapolis Unmet Need

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 3. Limits on Non-Service Funding

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

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

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

Grantee and Planning Council Roles and Responsibilities Role/TaskCEO/GranteePlanning Council Planning Council Formation/Membership (CEO) N/A Needs Assessment Comprehensive Planning Priority SettingN/A DirectivesN/A Resource AllocationN/A Coordination of Services Procurement N/A Contract Monitoring N/A Clinical Quality Management (SOC) Cost-Effectiveness and Outcomes - Evaluation ( option) Assessment of Administrative Mechanism

AreaGranteePlanning Council OperationsSupport, don’t direct PC Ensure budget for PC operations Develop and implement bylaws and policies Work with grantee to develop budget MembershipTypically a member Ensure open nominations process through review and selection of members Coordinate recruitment and nomination processes Ensure representation and reflectiveness Monitor member involvement Conflict of interestEnsure that grantee staff comply with conflict of interest Establish and enforce conflict of interest policy Grievance ProceduresEstablish procedures related to grantee functions Establish related PC functions Planning Council Functions

GranteePlanning Council Support needs assessment efforts Hire consultants Staff liaison Provide data Help access information Advice on areas of expertise Address grantee responsibilities in the assessment Take primary responsibility for needs assessment Form committee Design and plan the needs assessment Oversight of the process Consultant hiring Presentation of user friendly findings Present results Functions Needs Assessment

GranteePlanning Council Participate in Comprehensive Plan development Manage consultant vendor process Provide data for Comprehensive Plan Develop goal/objectives related to grantee areas of responsibility Help develop goals and objectives in areas of share responsibility Implement Plan components that involve grantee responsibilities Provide date to PC Play lead role in development of Comprehensive Plan Develop planning process and assign responsibility to a committee Work with grantee on hiring a consultant if necessary Set goals for areas of PC responsibility Help develop goals and objectives in areas of shared responsibility Implement Plan components that involve PC responsibilities Monitor progress in implementing plan Functions Comprehensive Planning

Functions Priority Setting GranteePlanning Council Assist PC in decision making on priorities Provide data to help with priority setting, such as service utilization data by service category Be present during the process to answer questions about grantee data Set priorities Ensure a sound process and criteria for priority setting Ensure that priorities are data based

GranteePlanning Council XX Develop budget for grantee administrative funds and QM funds Provide data to support the allocations process Help the PC estimate costs of bringing more people into care Prepare final budget for grant request Provide expenditure data to PC so they know of service category over/under spending Make recommendations to PC on reallocation of funds during the year Provide data to support PC decision making on carryover funds Prepare carryover requests to HRSA/HAB, consistent with PC decisions Allocate resources to priority service categories Where appropriate, separately allocate funds to subcategories within a broader service category Agree with grantee on PC support budget Develop or approve all reallocations involving changes from PC allocation decisions No role in determining the use of grantee administrative or QM funds If the grantee decides it cannot fully use administrative or QM funds, PC is responsible for reallocation of these funds. Functions Resource Allocation

GranteePlanning Council Requires providers to sign agreements with points of entry Ensure that providers help clients obtain other resources to support primary care and other services wherever possible, so that Part A is the payer of last resort Help PC identify other funding streams and share information about other available funding Ensure that PSRA considers other funding streams Ensure PC membership includes required representatives of other entities Collaborate with other publicly funded programs on needs assessment, estimation and assessment of unmet need, and development of a Comprehensive Plan Functions Coordination of Services

Roles and Responsibilities Other AreaGranteePlanning Council DirectivesUse directive in procurement and contracting Provide directives to grantee ProcurementImplementNo Role Contract MonitoringImplementNo Role Quality ManagementImplementProvide and periodically update standards of care that can be used in QM Use QM data in decision making Cost and Outcome EvaluationImplementOptional Assessment of Administrative Mechanism Provide information to PC to conduct assessment Inform PC about actions taken Conduct Assessment

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 Planning Council Formation and Membership

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 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.

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 Comprehensive Planning

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 Needs Assessment

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

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

Interpreting the Needs Assessment: Putting the Pieces Together

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

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 Priority Setting

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) Directives

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

Planning Council responsibility Process of deciding how much funding to allocate to each priority service category Must meet 7 5/25% 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 Resource Allocation

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 Reallocation

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 Coordination of Services

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 Procurement

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 Contract Monitoring

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 Clinical Quality Management

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 Cost-Effectiveness and Outcomes Evaluation

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 Assessment of the Administrative Mechanism

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 Planning Council Operations

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

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)

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

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

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

Summary Planning Council has clearly defined legislative responsibilities Planning Council decisions must be data-based, using the best available data Responsibilities are interrelated – emphasizing the importance of committee work Many functions best in collaboration with the Grantee