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Ryan White HIV/AIDS Program Part A Overview Administrative Reverse Site Visit September 19, 2019

Learn about the Ryan White HIV/AIDS Program, which provides comprehensive medical care, medications, and support services for low-income people with HIV. Over 500,000 individuals receive care through the program, improving health outcomes and addressing disparities.

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Ryan White HIV/AIDS Program Part A Overview Administrative Reverse Site Visit September 19, 2019

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  1. Ryan White HIV/AIDS ProgramPart A OverviewAdministrative Reverse Site VisitSeptember 19, 2019 Steven Young, Director Division of Metropolitan HIV/AIDS Programs HIV/AIDS Bureau (HAB)

  2. Health Resources and Services Administration (HRSA) Vision Healthy Communities, Healthy People Mission To improve health outcomes and address health disparities through access to quality services, a skilled health workforce, and innovative, high-value programs

  3. HIV/AIDS Bureau within HRSA

  4. HRSA HIV/AIDS Bureau (HAB) Vision and Mission Vision Optimal HIV/AIDS care and treatment for all. Mission Provide leadership and resources to assure access to and retention in high quality, integrated care, and treatment services for vulnerable people with HIV/AIDS and their families.

  5. Ryan White HIV/AIDS Program (RWHAP) • Provides comprehensive system of HIV primary medical care, medications, and essential support services for low-income people with HIV • More than half of people with diagnosed HIV in the United States – over 500,000 people – receive care through the RWHAP • Funds grants to states, cities/counties, and local community based organizations • Recipients determine service delivery and funding priorities based on local needs and planning process • Payor of last resort statutory provision: RWHAP funds may not be used for services if another state or federal payor is available Source: HRSA. Ryan White HIV/AIDS Program Annual Client-Level Data Report 2017 https://hab.hrsa.gov/data/data- report; CDC HIV Surveillance Supplemental Report 2016;21(No. 4)

  6. Clients Served by the Ryan White HIV/AIDS Program, 2017

  7. Clients Served by the Ryan White HIV/AIDS Program (non-ADAP), 2017

  8. Ryan White HIV/AIDS Program Clients, by Age Group, 2010 and 2017—United States and 3 Territoriesa a Guam, Puerto Rico, and the U.S. Virgin Islands.

  9. Clients Served by the Ryan White HIV/AIDS Program, by Race/Ethnicity, 2017—United States and 3 Territoriesa a Guam, Puerto Rico, and the U.S. Virgin Islands. bHispanics/Latinos can be of any race.

  10. Clients Served by the Ryan White HIV/AIDS Program, by Gender and Housing Status, 2017—United States and 3 Territoriesa a Guam, Puerto Rico, and the U.S. Virgin Islands.

  11. Clients Served by the Ryan White HIV/AIDS Program, by Poverty Level, 2017—United States and 3 Territoriesa a Guam, Puerto Rico, and the U.S. Virgin Islands.

  12. Health Outcomes of Clients Served by the Ryan White HIV/AIDS Program, 2017

  13. Viral Suppression among Clients Served by the Ryan White HIV/AIDS Program*, 2010–2017—United States and 3 Territories** • The percent of RWHAP clients virally suppressed has increased steadily from 69.5% in 2010 to 85.9% in 2017. • The Centers for Disease Control and Prevention estimates that in the United States, 59.8% of people diagnosed with HIV are virally suppressed. • Viral suppression outcomes lower among: • Younger age groups (13–24 years) • Specific minority populations • Clients with unstable housing *Puerto Rico, Guam, U.S. Virgin Islands Source: HRSA. Ryan White HIV/AIDS Program Annual Client-Level Data Report 2016. Does not include clients receiving only AIDS Drug Assistance Program services; CDC. HIV Surveillance Supplemental Report 2016;21(No. 4).

  14. Viral Suppression among RWHAP Clients (non-ADAP), 2010–2017—United States and 3 Territoriesa Viral suppression: ≥1 OAHS visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL. a Guam, Puerto Rico, and the U.S. Virgin Islands.

  15. Viral Suppression among RWAP Clients, by State, 2010 and 2017 – United States and 2 Territoriesa

  16. Viral Suppression among Key Populations Served by the Ryan White HIV/AIDS Program, 2010 and 2017—United States and 3 Territoriesa Hispanics/Latinos can be of any race. Viral suppression: ≥1 OAHS visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL. a Guam, Puerto Rico, and the U.S. Virgin Islands.

  17. RWHAP Part A Comprehensive System of Care

  18. Division of Metropolitan HIV/AIDS Programs_____________________________________ Mission: Provide leadership and promote access to and retention in high quality, community-based HIV care and accountability in HIV/AIDS programs implemented in impacted metropolitan areas.

  19. Organization 19

  20. HRSA HAB Project Officer Roles • Track, review, and approve • Grant reporting requirements • Conditions of Award • Submission of grant request • Technical assistance requests • Notice of Grant Awards (tracking) • Ongoing Monitoring • Monthly monitoring calls • Site visits – comprehensive, diagnostic, & TA • Help recipients improve the system of care • Needs Assessment • Service Planning • Service Delivery • Service Evaluation • Clinical Quality Mgmt. • Risk Management • Liaise and Respond • Recipient Needs • Program Activities

  21. Overarching RWHAP Part A Program Purpose & Key Facts The RWHAP Part A is intended to support comprehensive, community-based, outpatient HIV/AIDS care systemsfor delivering life-saving care and treatment to persons with HIV in metropolitan areas with the greatest number of HIV/AIDS cases. Of note: • Services are not an entitlement • RWHAP is the payor of last resort • Provides a continuum of care with equitable access throughout the service area • Key role for clients of RWHAP Part A services is through Planning Council and other types of involvement

  22. Emergency Relief Grants – RWHAP Part AFY 2019 Funding: $656 million • Provides grants to 52 Eligible Metropolitan Areas (EMAs) and Transitional Grant Areas (TGAs) that are most severely impacted by the HIV/AIDS epidemic: • Use established boundaries of Metropolitan Statistical Areas to generate HIV/AIDS case counts • EMAs have at least 50,000 inhabitants and >2,000 reported AIDS cases in the past 5-years • TGAs have at least 50,000 inhabitants and 1000 - 1999 reported AIDS cases in the past 5-years or prior status as an EMA • Award is made to the Chief Elected Official • Local funding allocations are determined by the legislatively required Planning Council 73% of people with HIV live in these areas

  23. Current EMAs (N=24) Atlanta, GA Baltimore, MD Boston, MA Chicago, IL Dallas, TX Detroit, MI Ft. Lauderdale, FL Houston, TX Los Angeles, CA Miami, FL Nassau-Suffolk, NY New Haven, CT New Orleans, LA New York, NY Newark, NJ Orlando, FL Philadelphia, PA Phoenix, AZ San Diego, CA San Francisco, CA San Juan, PR Tampa-St. Petersburg, FL Washington, DC West Palm Beach, FL

  24. Current TGAs (N=28) Austin, TX Baton Rouge, LA Bergen-Passaic, NJ Charlotte-Gastonia, NC-SC Cleveland, OH Columbus, OH Denver, CO Ft. Worth, TX Hartford, CT Indianapolis, IN Oakland, CA Orange County, CA Portland, OR Riverside-San Bernardino, CA Sacramento, CA Saint Louis, MO San Antonio, TX San Jose, CA Seattle, WA • Jacksonville, FL • Jersey City, NJ • Kansas City, MO • Las Vegas, NV • Memphis, TN • Middlesex-Somerset-Hunterdon, NJ • Minneapolis-St. Paul, MN • Nashville, TN • Norfolk, VA

  25. RWHAP Part A Eligible Metropolitan Areas (EMA) & Transitional Grant Areas (TGAs)

  26. RWHAP Part A Funding Distribution The RWHAP Part A grant includes formula, supplemental, and Minority AIDS Initiative (MAI) funds. • Formula grants(2/3) - based on living HIV/AIDS cases (as reported by CDC) in the EMA or TGA as of December 31 in the most recent calendar year for which data are available • Supplemental grants(1/3) - competitive and based on demonstrated need and other selective criteria • MAI - funding is awarded by formula according to the distribution of living HIV/AIDS cases among racial and ethnic minorities

  27. Limits on Non-Service Funding • Focus: Maximize funding for direct services • 10% administrative cap inclusive of planning, evaluation and Planning Council support • Another 5% (or $3.0 million, whichever is less) for Clinical Quality Management – assess quality of care and clinical outcomes

  28. Use-or-Lose Formula Funding • Penalty for unobligated & unliquidated funds • If more than 5% of formula funds are unspent at the end of the year, recipients are ineligible for supplemental funding • Unobligated formula balance is used to off-set future grant award Note: MAI is not counted toward the Unobligated Balance (UOB)

  29. Carryover RWHAP Part A recipients may submit a request to carryover UOB that remains at the end of a budget period. • Must remain a funded recipient in subsequent budget period. • Due 90-days at end of previous budget period and can be requested with FFR. • Activities proposed to be funded with carryover funds must be supported by legislative requirements and program expectations. • Must estimate and report any possible carryover of UOB of the current grant year each December in order to request carryover of funds.

  30. Components/Entities in RWHAP Part A Structure • Chief Elected Official – Official recipient of RWHAP Part A funds (mayor, county executive, chair county board of supervisors, freeholder, judge, etc.) • Recipient – Administrative agent for RWHAP Part A funds • Administrative or fiduciary agent – Retained by the CEO and/or recipient to assist in fulfilling administrative activities • Planning Council/Planning Body – Establishes plans and priorities for the area • Subrecipients – Core medical and support service providers

  31. Flow of RWHAP Part A Funds and Decision Making

  32. HRSA Expectations of EMAs/TGAs • Proper stewardship of grant funds • Program and fiscal monitoring of sub-recipients – National Monitoring Standards • Adherence to reporting requirements • Compliance to legislation • Appropriate membership of Planning Council

  33. Historical Context • Community health planning – a movement to make widely available coordinated health facilities, especially hospitals, & to foster their orderly & efficient development...that is, to meet need without duplication • Hill Burton (1946) – survey the need for & subsidize the construction of hospitals, mostly as voluntary, nonprofit institutions • Comprehensive Health Planning (1966) – formula grants for statewide comprehensive health planning under a single agency, guided by a representative advisory council with a majority of clients • National Health Planning & Resources Development Act (1974) – mandated Certificate of Need (CON) for new or expanded health facilities, with local council review/recommendations to the state • RWJ AIDS Health Services Program (1985) – attempt to model the community-based response in San Francisco across other hard-hit U.S. cities • HRSA AIDS Service Demonstration Projects (1987) – 4 cities initially, utilized representative planning bodies to inform projects • HIV Health Service Planning Grants (1988) – to assist states in early years of the epidemic Ryan White Care Act – unique among federal grant programs in terms of RWHAP Part A planning requirements & involvement

  34. RWHAP Part A Planning Council Overview

  35. Recipient and Planning Council Roles • Recipient and Planning Council = two independent entities, both with legislative authority and roles • Some roles belong to one entity and some are shared • Memorandum of Understanding codifies relationship • HRSA HAB recommends separation of duties to avoid confusion of roles • Effectiveness requires communication, information sharing, and collaboration between the recipient, Planning Council, and Planning Council support staff – with ongoing involvement of the community & people with HIV

  36. Recipient and Planning Council Roles & Responsibilities

  37. Planning Council Membership Overview • Reflectiveness – of local epidemic • Open nominations and conflict-of-interest provisions • Representation – 13 required categories of various providers, government officials, people with HIV, and others • 33% of Council membership are to be unaligned people with HIV • DMHAP – Part A Planning Council and Planning Body Technical Assistance (TA) provided by Community HIV/AIDS Technical Assistance and Training for Planning Project (Planning CHATT)

  38. RWHAP Part A Key Program Requirements

  39. Comprehensive Planning • Integrated HIV Prevention and Care Plan GUIDANCE, Including the Statewide Coordinated Statement of Need, CY 2017- 2021 • FY 2019 National TA Cooperative Agreement to assist RWHAP Parts A and B recipients

  40. RWHAP Part A Site Visits • Comprehensive Site Visits (CSVs) – Once every 4 yrs. Components/Modules Include: 1) Site Visit Desk Reference 3) Fiscal 5) Subrecipient 2) Administrative/Program 4) CQM CSVs >> SV Report >> TA & Corrective Action Plan • Example: CQM budgets often include admin costs for QA or data • Diagnostic Site Visits Completed to examine and analyze problems/issues/needs. • Technical Assistance Site Visits These are completed to provide on-site TA

  41. RWHAP Core Medical Services

  42. RWHAP Core Medical Service Requirement • Core Medical Services: RWHAP Parts A, B, C funded recipients are required to spend at least 75% of grant funds on: • Support Services are defined as services that are needed for people with HIV to achieve their medical outcomes. Title XXVI Section 2604(c)of the Public Health Service Act

  43. RWHAP Part A Core Medical Services 1.Outpatient ambulatory health services 2-3. Medications: AIDS Drug Assistance Program (ADAP) & Local Pharmaceutical Assistance Programs (LPAP) 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

  44. RWHAP Part A 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 translation) • Medical transportation services 10. Outreach services 11. Psychosocial support services • Referral for health care/ supportive services • Rehabilitation services • Respite care • Substance abuse services – residential • Treatment adherence counseling • Services Provided through Consortia*

  45. How Does a Recipient Qualify & Applyfor a Waiver? The Public Health Service Act grants HRSA authority to waive the Core Medical Services requirement if: • The recipient is funded by RWHAP Parts A, B, or C • There are no ADAP waiting lists in the applicant’s state • Core Medical Services are available to all eligible individuals in the applicant’s state, jurisdiction, or service area A waiver application must be submitted before the recipient’s annual grant application, within the grant application, or after the annual grant application – up to 4-months into the grant cycle. Instructions for Waivers can be found at: https://hab.hrsa.gov/sites/default/files/hab/Global/13-07waiver.pdf

  46. RWHAP Part A Core Medical Services Waiver Requests and Approvals 2013-2019

  47. Summary of RWHAP Part A Issues & Initiatives

  48. Recent RWHAP Part A Projects Planning CHATT (PC) https://targethiv.org/planning-chatt (7/17-6/20) RWHAP Integrated HIV/AIDS Planning and Resource Allocation Cooperative Agreement (7/19-6/23) Building Capacity for HIV Elimination in Ryan White HIV/AIDS Program Part A Jurisdictions Cooperative Agreement (7/19-6/21) RWHAP Measuring Unmet Need for HIV-Related Service Delivery (9/18-9/20) Alternate Resource Allocation Methodologies for Parts A/C Phase II (8/17-7/20) Jurisdictional Public Health Approach to HCV Diagnosis/Treatment of Co-infected Individuals (3-Part A Jurisdictions participated) (9/16-9/19) Addressing the HIV Care Continuum in Southern Metropolitan Areas (9/16-8/19) Care continuum learning collaborative https://targethiv.org/ta-org/cclc  (9/15-7/19)

  49. Summary of Relevant RWHAP Part A Issues Leading the RWHAP Part A program to translate our vision of zero new HIV infections into a reality. • Changing leadership & resources • Core medical service waivers • Integration of prevention & care & collaboration across RWHAP Parts • Adoption of model programs using PCN 16-02 • Use &role of fiduciary agents • Collaboration & planning related to ending the HIV epidemic • PC/PB requirements & recipient relationship • Sub-recipient monitoring (site visits, service standards, program income) • Clinical quality management • Challenges to local procurement processes • Lawsuits • Audit resolution

  50. Ending the HIV Epidemic: A Plan for America

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