1. Continuing HIV Care Services in the Absence of Ryan White Funding Interfaith Community Health Center Bellingham, Washington

2. What We Decided In February 2014, the ICHC Board of Directors voted unanimously to relinquish the clinic’s Part C grant effective March 31, 2014. Grant amount was approximately $400,000. ICHC was an April 1 start date with one year left in grant cycle before re-competition. ICHC had been a Ryan White grantee for 11 years. ICHC’s Ryan White Program offered a comprehensive program of primary care, dental, case management, behavioral health, and nutrition services. One Ryan White patient is a ICHC Board Member.

3. However… Board also voted unanimously to continue the same array of services offered through our Ryan White Program using other funding sources (e.g., 340b and Medicaid expansion revenue)

4. Why We Did It Unique nature of ICHC clinic FQHC with approximately 14,000 patients Only about 170 HIV patients No stand-alone HIV program, so… Different eligibility process for HIV patients vs. other clinic patients (e.g., income verification every 6 months, even if insured, and residency documentation – not required of any other clinic patients) Different Ryan White sliding fee scale rules vs. 330 rules (e.g., no charge for patients below 100% FPL, slide beyond 200% FPL) Clinic EMR with CAREWare double entry Considerable drain on Finance, Front Desk, and Medical Records

5. Why We Did It (continued) ACA implementation Fewer uninsured patients Likely grant underspend into the future Strong safety net in Washington State through state’s Early Intervention Program (although Medicaid patients are categorically ineligible) Coverage for undocumented patients Comprehensive dental coverage Assistance with co- pays/premiums/deductibles

6. Why We Did It (continued) Increasing administrative burden Eligibility verification twice annually Very likely to have required a core services waiver Had increase administrative staffing.2 FTE to handle eligibility documentation Administrative requirements were becoming an impediment to quality care Paper chasing by medical staff Frustrated patients Frequently changing requirements meant frequent “system change,” which was disruptive to program efforts

7. Why We Did It (continued) Cost shifting – We were covering more of the costs of care with non-grant funds anyway Guidance that more costs (e.g., medical records, referrals, front desk) categorized as administrative costs Patients with lapsed eligibility documentation couldn’t be billed to grant Compliance concerns Retroactive policy clarifications

8. What Has Happened Continue to provide same services we have historically provided – same staff, same services Continue to contract with our case management partners If anything, the relationship has become stronger They have been understanding of our decision Continue to have a Consumer Advisory Group Continue to track HAB measures, with a few slightly modified, for QI program No change in number of HIV patients served

9. What Has Happened (continued) Time to “drill down” into quality measures and refine systems that should have been addressed long ago Moving towards implementation of a Hepatitis C program Focusing more on engagement/retention Expanding some RW benefits to other clinic patients (e.g., HIV nutritionist will start offering classes to patients with HIV and other chronic conditions)

10. What Has Happened (continued) Plans to work more with community partners on prevention and moving to opt- out HIV testing Patients have rolled with the change Those with incomes above 200% FPL are no longer eligible for the sliding fee scale, in compliance with 330 rules

11. What Has Happened (continued) If there’s a gap, it’s dental Medicare and privately-ensured patients have strong dental coverage through Early Intervention Program Medicaid adult dental program is not as generous Working through gaps in care for Medicaid patients in partnership with our case management contractor